Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study

Background: The maternal and neonatal mortalities in Ethiopia are high. To achieve the Sustainable Development Goals, innovations in ultrasound scanning and surveillance activities have been implemented at health centers for over 2 years. This study aims to estimate the contribution of obstetric ultrasound services on averted maternal and neonatal morbidities and mortalities in Ethiopia. Methods: A retrospective facility-based cross-sectional study design was conducted in 25 selected health centers. Data were extracted from prenatal ultrasound registers. SPSS version 25 was used for analysis. To claim statistically significant relationship among sartorial variables, a chi-square test was analyzed and P < 0.05 was the cut-off point. Results: Over the 2 years, 12,975 pregnant women were scanned and 52.8% of them were residing in rural areas. Abnormal ultrasound was reported in 12.7% and 98.4% of them were referred for confirmation of diagnosis and treatment. The ultrasound service has contributed to the prevention of 1,970 maternal and 19.05 neonatal morbidities and mortalities per 100,000 and 1,000 live births respectively. The averted morbidities and mortalities showed a statistically significant difference among women residing in rural and semi-urban areas, X,2 df (10) = 24.07, P = 0. 007 and X,2 df (5) = 20.87. P = 0.00, 1 respectively. Conclusion: After availing the appropriate ultrasound machines with essential supplies and capacitating mid-level providers, significant number of high-risk pregnant women were identified on time and managed or referred to health facilities with safe delivery services. Therefore, scaling-up limited obstetric ultrasound services in similar setups will contribute to achieving the Sustainable Development Goals by 2030. It is recommended to enhance community awareness for improved utilization of ultrasound services by pregnant women before the 24th week of gestational age. Ethiopia has adopted a federal government structure by establishing 11 regional states and two city administrations [24]. More than 80% of the population lives in rural areas. The national health system is divided into three tiers. Primary healthcare is led by a health center and typically five satellite health posts, targeting 25,000 people [24]. A health center is expected to provide health promotion, disease prevention, curative, and rehabilitative outpatient care including basic laboratory and pharmacy services with a capacity of 10 beds for emergency and delivery services [25]. This study targeted Amhara, Oromia and Southern Nations Nationalities and Peoples’ (SNNP) regions of the country. These regions were purposively selected with a criterion where limited obstetric U/S scanning services were introduced at the health center level to improve quality and equity of prenatal care for over 2 years. There are about 82.6 million residents in the study targeted regions. In line with the long-term outcomes of the United States Agency for International development (USAID) Transform: Primary Health Care project, 100 health centers were selected and supported with portable U/S machines [26]. A retrospective facility-based cross-sectional study design was employed to estimate the contribution of introduction of obstetric U/S services at health centers on averted maternal and neonatal morbidities and mortalities between January 2019 and December 2020. In Ethiopia, to increase access to healthcare technology among pregnant women of rural residents, the USAID Transform: Primary Health Care project introduced innovative U/S scanning services at the health center level, which are located close to rural communities of Ethiopia [26, 27]. To initiate the services, in October 2018, the project capacitated mid-level health professionals (mainly midwives) to offer limited obstetric U/S scanning services through task shifting/sharing principles [28, 29]. The knowledge and skill building activity was executed through a 10-day classroom basic limited obstetric ultrasound training supplemented with experiential learning events under supervision of Gynecologist/Obstetricians and Radiologists. In addition, three sessions of objective structured clinical examination (OSCE) followed by onsite and offsite mentoring/coaching sessions were facilitated [30]. A competent certified mid-level health professional can operate ultrasound machines and identify normal pregnancy, first trimester pregnancy and complications, fetal dating and measurements, second and third trimester pregnancy and complications. In addition, the trained and competent health professionals were equipped with the necessary equipment, supplies, and a place to refer women to. This was intended to enable health professionals to confirm pregnancies using U/S scanning services and identify high risk cases, to link women with the next level health facility that has functional Emergency Obstetric and Newborn Care (EmONC) services—ultimately ensuring safe deliveries [26, 27]. The sample size was determined based on the recommended rule of thumb that if the health centers are between 50 and 100, a 20 to 30% sample should be taken [31]. Hence, out of the 100 health centers providing limited obstetric U/S scanning services, for this study, the investigators sampled 25 health centers and selected targeted facilities using systematic random sampling techniques, where the sampling interval (k) is 3 (Fig. 1). Once the health center was identified, the information of all prenatal obstetric U/S service beneficiaries was included in the study. Schematic presentation of sampling techniques, 2020 The data collectors were 25 midwives who attended basic U/S scanning training and were also trained for 2 days on the tools and principles of data collection. In addition, five supervisors who are experts on maternal and neonatal health services were assigned to check and maintain the quality of collected data. As part of introducing U/S services in Ethiopian health centers, a logbook was developed and distributed to each intervention health facility (Additional file 1). The questionnaire was developed after reviewing relevant literatures [12, 13, 15–17, 20, 29]. The data sheet consists of demographic information of obstetric U/S service beneficiaries, including medical record number, age, and residential address. In addition, the trained mid-level health professionals who operated the U/S machines documented the indications for U/S scanning, gestational age estimated based on Last Menstrual Period (LMP) and U/S scanning findings, fetal biometry measurements, U/S diagnosis, action taken, and reasons for offered referral services. This information was extracted and entered to a Microsoft Excel 2016 (Microsoft Inc., Seattle WA) spreadsheet program for data storing, transferring, and cleaning. Using a predefined criterion, the abnormal U/S scanning reports were categorized based on their potential to cause catastrophic maternal and neonatal health outcomes. The magnitude of risk for maternal morbidities and mortalities were estimated as percent of possible maternal morbidities and mortalities over total ultrasound scan through considering cases of fetal malpresentation, abnormal placentation, multiple fetus, small or large gestation age, intrauterine fetal death (IUFD) or fetal demise, gross anomalies, abnormal fluids, abortion, ectopic pregnancy, and pelvic pathology as a numerator, and all U/S scanning report as denominator. In addition, the possibility of neonatal morbidity and mortality was estimated using percent of possible neonatal morbidities and mortalities over total ultrasound scan through the following cases of abnormal U/S scanning reports: fetal malpresentation, oligo-hydramnios, polyhydramnios, small or large for gestation age, and multiple fetus as a numerator, and all ultrasound scanning reports were the denominator. Therefore, the investigators decided to consider all possible risks for maternal and neonatal morbidities and mortalities in risk averted estimations, which can be reduced through confirmation using advanced perinatal health services accessed through referral linkage. The dependent variables were abnormal U/S scanning surveillance reports with possibilities of catastrophic maternal and neonatal perinatal health outcomes. The independent variables were residential addresses and intervention regions. The inclusion criteria were all Vscan limited obstetric ultrasound service beneficiaries during ANC from January 2019 through December 2020. The exclusion criteria were ANC service beneficiaries between January 2019 and December 2020 who did not receive ultrasound scanning services. First, descriptive statistics for all dependent and independent variables were calculated. The age of pregnant women, a continuous variable, was summarized using mean [± standard deviation (SD)]. The rest of the categorical variables were presented using frequencies and percentages. The Pearson Chi-square test was used to evaluate the differences among categorical variables. The statistical differences were claimed at P-value < 0.05. IBM SPSS Statistics for Windows, version 25 was used in the data analysis [32].