Ultrasonography in Low-Resource Settings: Approaches to Implementation
Our first post on ultrasonography looked at utility and demand patterns for ultrasound in low-resource settings. However, we know to improve the quality of antenatal care provided, many aspects of the health system must be functional.
“The ultrasound machine is of no use unless you’ve got someone to operate it. Ultrasound is a diagnostic tool; it’s an investigation, not a treatment. It’s not going to improve pregnancy any more than knowing a woman’s hemoglobin level is going to improve her anemia levels. You need to embed your ultrasound into a decision-making algorithm or a process that allows you to act on the information,” says Dr. Aris Papageorghiou, Senior Fellow in Clinical Medicine and Clinical Research Director at the University of Oxford’s Maternal and Perinatal Health Institute. The investigation and interpretation needs to be of high-quality, and the facility requires the strength to act on the result of an ultrasound investigation by recommending and supporting the appropriate care intervention in order to improve maternal and perinatal health.
The approaches for overcoming this ultrasound “implementation gap” in low-resource settings largely focus on training the user of the technology, and/or adapting the technology to fit the context.
Several studies have shown that health workers can successfully be trained to take quality ultrasound scans. A malaria in pregnancy project in Malawi recommends that health workers be trained to confirm gestational age and avoid misclassification of infants as premature or growth-restricted. In a refugee camp on the Thai-Burmese border, locally-trained health workers were successfully trained on how to take ultrasound measurements for an ongoing fetal growth study. In both examples, the scans were taken by health workers in a health facility and were interpreted by a higher cadre of obstetric care providers.
Dr. Danstan Bagenda, a Research Associate at Harvard School of Public Health, is interested in whether Community Health Workers (CHWs) can also be trained to perform, and perhaps interpret, ultrasound scans in Uganda to improve the country’s sluggish maternal and newborn mortality rates. “Community Health Workers are already interacting with mothers very early on [in pregnancy]; why not have that interaction be of some use?” says Dr. Bagenda. CHWs are charged with identifying pregnancies, but according to Dr. Bagenda the decisions whether or not to seek facility-based antenatal care is “passive.” He wonders if CHWs were trained to perform ultrasound scans, the resulting information could be used to more effectively link women to facility-based care.
With increasing market opportunities for medical diagnostic companies in low- and middle-income countries, these private sector actors are adapting to meet complex needs in low-resource settings. Examples of these adaptations include:
- Portable, handheld ultrasounds with a simplified interface paired or integrated with a PC, tablet or smartphone for easy use at the point of care
- Minimal consumables and servicing needs to ensure long-term affordability
- Rechargeable batteries through electricity and/or solar power to overcome infrastructure constraints
- Connected devices that transmit scanned images through Bluetooth or mobile connections for teleradiology
- Public-private partnerships to reach key product users with training on use and maintenance of ultrasounds
New developments in clinical research may be opening up new pathways for implementing effective ultrasonography in low-resource settings. A new, internationally-applicable equation for estimating gestational age through ultrasound and global standards for fetal growth will be produced by the INTERGROWTH-21st Project. Importantly, a Randomized Control Trial is currently underway to evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings.
Do you have an opinion on the feasibility of ultrasound in low-resource settings? Do you want to share your experience with health workers training to use and/or interpret ultrasound? Please contact Katie Millar for more information on being a guest blogger for the MHTF.