Abstract
In settings where antenatal ultrasound is not offered routinely, ultrasound use when a woman first presents to the maternity ward for labour (i.e., triage) may be beneficial. This study investigated patients’ perceptions of care and providers’ experience with ultrasound implementation during labour triage at a district referral hospital (DH) and three primary health centers (HC) in eastern Uganda. This was a mixed methods study comprising questionnaires administered to women and key informant interviews among midwives pre- and post-ultrasound introduction. Bivariate analyses were conducted using chi-square tests. Qualitative themes were categorized as (1) workflow integration; (2) impact on clinical processes; (3) patient response to ultrasound; and (4) implementation barriers. A total of 731 and 815 women completed questionnaires from the HCs and DH, respectively. At the HC-level, triage quality of care, satisfaction and recommendation ratings increased with implementation of ultrasound. In contrast, satisfaction and recommendation ratings did not differ upon ultrasound introduction at the DH, whereas perceived triage quality of care increased. Most participants noted a perceived improvement in midwives’ experience and knowledge upon introduction of ultrasound. Women who underwent a scan also reported diverse feelings, such as fear or worry about their delivery, fear of harm due to the ultrasound, or relief after knowing the baby’s condition. For the midwives’ perspective (n = 14), respondents noted that ultrasound led to more accurate diagnoses (e.g., fetal position, heart rate, multiple gestation) and improved decision-making. However, they noted health system barriers to ultrasound implementation, such as increased workload, not enough ultrasound-trained providers, and irregular electricity. While triage ultrasound in this context was seen as beneficial to mothers and useful in providers’ clinical assessments, further investigation around provider-patient communication, system-level challenges, and fears or misconceptions among women are needed.
Highlights
Utilization of obstetric ultrasound in many low-and middle-income countries (LMICs) has increased due to improvements in machine durability, portability, and affordability [1–5]
This mixed-methods study was nested within two studies that were conducted at a district hospital (DH) and three health centers (HCs) in eastern Uganda
Phase 1 introduced an intake log to register all women who presented at the maternity ward, and an outcome form for baseline assessment; Phase 2 introduced a triage checklist that guided clinical assessment and decision-making at labour triage, and provided support for patient transport in case of a referral from the HC to the district referral hospital (DH); Phase 3 introduced both the checklist and midwife-administered limited obstetric ultrasound at labour triage
Summary
Utilization of obstetric ultrasound in many low-and middle-income countries (LMICs) has increased due to improvements in machine durability, portability, and affordability [1–5]. Previous studies in LMICs indicate that trained midwives have the capacity to diagnose different obstetric conditions using ultrasound during pregnancy [6,7]. 17% of scans prompted a change in clinical decision-making, such as increased antenatal care visits, referral, admission for observation, or labour induction. 14 health centre midwives in rural southwest Uganda were trained over a 6-week period to conduct limited, screening obstetric ultrasound. They demonstrated that ultrasound corrected clinical exam findings 6.7% to 12% of the time, including identification of early pregnancy complications (e.g., ectopic pregnancy, incomplete/compete abortion), as well as malpresentation and multiple gestation [9]. Midwife-administered ultrasound may be valuable in early and accurate diagnosis of certain conditions during pregnancy, and subsequent clinical decision-making
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