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Background: Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed. Objectives: To explore Rwandan midwives’ experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects. Methods: A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS). Results: Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed. Conclusions: Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda.
A qualitative study design was employed. Data were collected through focus group discussions (FGDs) with midwives and analysed using content analysis [37]. This study is part of the CROss Country Ultrasound Study (CROCUS), an international study that aims to explore midwives’ and obstetricians’ experiences and views of the use of ultrasound in pregnancy management in low-, middle- and high-income countries. The countries participating in CROCUS are Rwanda, Tanzania, Vietnam, Australia, Norway and Sweden. Three district hospitals, two university teaching hospitals and one private hospital in rural and urban areas of Kigali and in the Southern province of Rwanda were selected for recruitment. The number of births at the selected hospitals ranged between 1400 and 4500 annually. The hospitals were purposively selected to include participants at all healthcare levels that provide obstetric ultrasound in urban and rural areas, to gain a broad range of experiences. The recruitment was organised by the two local researchers, JN and JPS. The Ministry of Health approved the study and the heads of the selected health facilities assisted with the recruitment of participants working within maternity care. Participants of varying age and with various lengths of work experience were sought. Because of the high workload at the study sites, all available midwives at the time of each FGD were invited to participate, regardless of their background. The size of the focus groups varied from two to six participants depending on the availability of midwives at each selected health facility. Twenty-three midwives participated in the study, all females. The mean age was 32.6 years (range 25–47 years). The mean length of work experience in maternity care was 6.5 years (range 1 month to 19 years). Two participants reported special training in ultrasound. Participant characteristics are presented in Table 1. Characteristics of midwives (n = 23) participating in focus group discussions (FGDs). Data collection was undertaken during 1 week in January 2015. Before the start of each FGD, all participants were provided with written information about the study, a consent form to sign and a brief questionnaire on their background characteristics. The FGDs were held in Kinyarwanda. To make sure that all topics of interest were covered in each FGD, an interview guide, previously developed by the CROCUS team, was used (Table 2). The same interview guide has been used across all six countries participating in CROCUS. The topics were not discussed in a predefined order, to allow participants to talk freely and at length. The FGDs were conducted by one member of the research team (JPS), and two other members (KE and AÅ) attended as observers. Notes were taken on informal communication and any disrupting factors, for example interruption because of a medical emergency at the clinic. The FGDs were digitally recorded and lasted for 25–45 min (mean of 35 min). Data saturation, i.e. where no new information was forthcoming [38], was assessed to have been reached after six FGDs. Key domains in the CROss Country Ultrasound Study (CROCUS) interview guide. All recordings were transcribed verbatim and translated from Kinyarwanda to English by an external person. The moderator (JPS) control-read the transcriptions while simultaneously listening to the recorded FGD. To check the consistency of the translation, another person outside the research team back-translated parts of the English version to Kinyarwanda. Some specific words were found to differ, but the sense of the whole was the same. Data were analysed using qualitative content analysis, inspired by Graneheim and Lundman [37]. The transcriptions were read several times by two of the authors (SH and IM) to gain a sense of the whole. First, meaning units were identified, condensed and coded by SH. Secondly, all coded data were reviewed by IM and some additional codes were noted. Thirdly, SH and IM discussed and sorted the codes into content areas, based on their similarities and differences. Thereafter, the content areas were categorised into preliminary categories and subcategories. SH and IM discussed the findings of the primary analysis, and an overall theme, four categories and their 10 subcategories were developed during this process. The analysis was an iterative process, moving back and forth between text, codes, subcategories and categories [37]. Examples of text, codes and categories generated from content analysis of FGDs are presented in Table 3. In cases of uncertainty, the recordings were listened to again, and the transcribed text was reanalysed to clarify the participants’ statements. Later during analysis, all authors reviewed the preliminary results and discussed the findings until consensus was reached. Examples of text, codes and categories generates from content analysis of focus group discussions.
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