Institutionalization of limited obstetric ultrasound leading to increased antenatal, skilled delivery, and postnatal service utilization in three regions of Ethiopia: A pre-post study

PLoS ONE, Volume 18, No. 2 February, Year 2023

Interprétation

Background A minimum of one ultrasound scan is recommended for all pregnant women before the 24th week of gestation. In Ethiopia, there is a shortage of skilled manpower to provide these services. Currently, trained mid-level providers are providing the services at the primary healthcare level. The aims of this study were to compare antenatal care 1 (ANC1), antenatal care 4 (ANC4), skilled birth attendance (SBA), and postnatal care (PNC) service utilization before and after institutionalizing Vscan limited obstetric ultrasounds at semi-urban health centers in Ethiopia. Methods A pre and post intervention observational study was conducted to investigate maternal and neonatal health service utilization rates before and after institutionalizing Vscan limited obstetric ultrasound services, between July 2016 and June 2020. The data were extracted from 1st August– 31st December 2020. Results The observed monthly increase on the mean rank of first ANC visits after the introduction of Vscan limited obstetric ultrasound services showed a statistically significant difference at KW-ANOVA H (3) = 17.09, P = 0.001. The mean rank of fourth ANC utilization showed a statistically significant difference at KW- ANOVA H (3) = 16.24, P = 0.001. The observed mean rank in skilled birth attendance (SBA) showed a statistically significant positive difference using KW-ANOVA H (3) = 23.6, P<0.001. The mean rank of increased utilization in postnatal care showed a statistically significant difference using KW-ANOVA H (3) = 17.79, P<0.001. Conclusion The introduction of limited obstetric ultrasound services by trained mid-level providers at the primary healthcare level was found to have improved the utilization of ANC, SBA, and postnatal care (PNC) services. It is recommended that the institutionalization of limited obstetric ultrasound services be scaled up and a further comparative study between facilities with and without ultrasound services be conducted to confirm causality and assess effects on maternal and perinatal outcomes. A pre- and post-intervention observational study was conducted to understand maternal and neonatal health service utilization rates before and after institutionalizing Vscan limited obstetric ultrasound services between July 2016 and June 2020. The actual data extraction was made from 1st August to 31st December 2020. The study was conducted in Amhara, Oromia, and Southern Nations, Nationalities and Peoples’ (SNNP) regions. These regions were selected due to the presence of Vscan limited obstetric ultrasound services in the selected health centers, for over two years. A health center is a public health facility within the primary healthcare system of Ethiopia, serving up to 25,000 people and has a mandate to provide promotive, preventive, curative, and rehabilitative outpatient care including basic laboratory and pharmacy services with a capacity for 10 beds for emergency and delivery services [12]. USAID funded the USAID Transform: Primary Health Care project (June 2016-June 2020) to support the MoH in line with its long-term goal of preventing child and maternal deaths (PCMD) [28]. To improve access to, and quality and equity of basic maternal and neonatal health services, the project, in collaboration with its technology partner General Electric Healthcare introduced Vscan access—a small portable ultrasound device—for obstetric scanning by trained mid-level healthcare providers [29]. The project strategizes to increase SBA through introducing ANC limited obstetric ultrasound services and improving the proper management of identified complications of pregnancies in referral health facilities, all of which contribute to maternal, fetal, and neonatal positive health outcomes [28, 30]. Vscan ultrasound machines with seed supplies were provided to each of the targeted 100 health centers after successfully providing basic limited ultrasound classroom and practical hands-on training for 10 days. The trainees were 219 mid-level healthcare providers who lacked knowledge and skills on the technology [31]. In addition, the training was supplemented with three sessions of monthly coaching, each lasting for two days, and the provision of virtual real-time feedback. Service initiation was supported through awareness creation and dissemination of information on ultrasound service availability at the health center level using all community engagement platforms including pregnant women conferences, women development army meetings, and house to house visits by health extension workers [28]. To ensure the quality of ultrasound services, a continuous mentorship was carried out by government and project staff. Pregnant women with detected abnormalities during scanning were referred to nearby hospitals for confirmation of diagnoses and further care. The number of women that received ultrasound scanning services during the first, second, third, or more trimester periods within the two years after the introduction of the services were 10,186, 2,974, and 1,509, respectively. Based on the 2007 national census, the projected population of the residents of targeted areas were 1.10 million in the year 2017. At the endpoint (2020), there were about 1.19 million people living within the study areas. Of these, the estimated number of pregnant women eligible for maternal and neonatal health services for the year 2020 were 40,506 (3.4%). The majority (13/30) of the health centers were enrolled from within the Oromia Region. On average, each health center is located 58.6 kilometers away from a referral receiving hospital (Table 1). The sample size was determined using the rule of thumb recommendation of The Aga Khan Foundation (1997) [32]. Thirty health centers were sampled i.e., 30% of the 100 health centers. The three regions were selected based on the accessibility and functionality of the ultrasound services during the time of data collection. Finally, a simple random sampling technique was applied to identify individual facilities. Three supervisors and 30 data collectors who are health science professionals were recruited from the targeted three regions. A two-day training on the objectives of the study, data collection techniques, ethical principles, and field pretesting was carried out. The data were extracted from a routine health information management system (HMIS) database using a pre-tested tool. To ensure the quality of data, three trained supervisors with master’s degrees in public health were deployed in the field and provided close technical support, with feedback given daily to the data collectors. The supervisors were responsible for checking and rechecking the collected data for completeness and consistency. The dependent variables were summary aggregated continuous data [33] of ANC1, ANC4, SBA, and PNC service reports. The independent variables were years of service. The data were entered and cleaned using Microsoft Excel 2016 and exported to SPSS V25 for descriptive and inferential analysis. The service utilization coverages were compared based on institutionalization of Vscan limited obstetric ultrasounds using 1,440 aggregate data collected from the 30 health centers (S1 File). In addition, for this study, the steps and procedures of Ross et al., (2013) were adopted [14]. The results of the statistical tests were presented using tables and graphs. To analyze F tests (one-way analyses of variance, ANOVA), the data violated the assumption of homogeneity of variances of a parametric test using Shapiro-Wilk test of normality P<0.05 (S2 File). Hence, the Kruskal-Wallis H test or a ‘one-way ANOVA on ranks’ which is an equivalent non-parametric test was employed to determine statistically significant differences between four groups of independent variables i.e., years of service. The statistical differences were claimed at P<0.05. However, the investigators maintained and ensured the following assumptions of the Kruskal-Wallis H test: (1) the dependent variables (ANC, SBA, and PNC) are interval data, (2) the independent variable has four categories, (3) there was no relationship between observations in each group, and (4) the distribution of scores in each group were not identical [28]. Finally, a statistical analysis was employed to compare data from twenty-four months (2017 and 2018) preceding the introduction of Vscan limited obstetric ultrasound services and twenty-four months (2019 and 2020) following the intervention. The mean rank monthly first ANC, fourth ANC, SBA, and PNC were compared before and after ultrasound services were initiated using a nonparametric test called the Kruskal-Wallis H test. Post hoc analysis using the KW-ANOVA H mean rank test was conducted with a Bonferroni correction applied. A statistical test result with a P-value of <0.0125 indicated the presence of a significant difference between service coverages over four years on ANC1, ANC4, SBA, and PNC.

Résumé de l’IA

Study Justification:

– The study aimed to investigate the impact of institutionalizing limited obstetric ultrasound services on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) service utilization in Ethiopia.
– The study addressed the shortage of skilled manpower to provide ultrasound services in the country.
– The findings of the study would provide evidence on the effectiveness of introducing limited obstetric ultrasound services at the primary healthcare level.

Study Highlights:

– The study found a statistically significant increase in the utilization of ANC1, ANC4, SBA, and PNC services after the introduction of Vscan limited obstetric ultrasound services.
– The mean rank of first ANC visits, fourth ANC utilization, skilled birth attendance, and postnatal care showed statistically significant positive differences.
– The results suggest that the institutionalization of limited obstetric ultrasound services by trained mid-level providers improved the utilization of maternal and neonatal health services.

Recommendations for Lay Reader:

– The study recommends scaling up the institutionalization of limited obstetric ultrasound services in Ethiopia.
– It suggests conducting a comparative study between facilities with and without ultrasound services to confirm causality and assess the effects on maternal and perinatal outcomes.
– The findings highlight the importance of providing access to ultrasound services during pregnancy to improve the utilization of antenatal, skilled delivery, and postnatal care.

Recommendations for Policy Maker:

– The study recommends integrating limited obstetric ultrasound services into the primary healthcare system in Ethiopia.
– It suggests allocating resources to train mid-level healthcare providers in ultrasound technology and providing them with the necessary equipment.
– The findings emphasize the need for policy support and funding to scale up the provision of ultrasound services in order to improve maternal and neonatal health outcomes.

Key Role Players:

– Ministry of Health: Responsible for developing policies and guidelines for the integration of limited obstetric ultrasound services into the healthcare system.
– Healthcare Providers: Trained mid-level healthcare providers who will be responsible for delivering ultrasound services.
– Training Institutions: Institutions that provide training programs for mid-level healthcare providers in ultrasound technology.
– Donor Organizations: Organizations that can provide funding and support for the procurement of ultrasound equipment and training programs.

Cost Items for Planning Recommendations:

– Training Programs: Budget for training mid-level healthcare providers in ultrasound technology.
– Equipment Procurement: Budget for purchasing ultrasound machines and related supplies.
– Infrastructure Development: Budget for creating suitable spaces for ultrasound services in health centers.
– Awareness and Outreach: Budget for conducting awareness campaigns and disseminating information about the availability of ultrasound services.
– Quality Assurance and Monitoring: Budget for continuous mentorship and supervision to ensure the quality of ultrasound services.
Please note that the provided cost items are general categories and the actual cost estimation would require a detailed assessment and planning process.

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is rated 8 because it provides a clear description of the study design, data collection methods, and statistical analysis. The study conducted a pre- and post-intervention observational study to investigate the impact of institutionalizing Vscan limited obstetric ultrasound services on maternal and neonatal health service utilization rates in Ethiopia. The data were collected from July 2016 to June 2020, and the study was conducted in three regions of Ethiopia. The results show statistically significant differences in the utilization of antenatal care, skilled birth attendance, and postnatal care after the introduction of ultrasound services. The conclusion recommends scaling up the institutionalization of ultrasound services and conducting further comparative studies. To improve the strength of the evidence, the abstract could include more details on the sample size calculation, data collection tools, and limitations of the study.

Abstrait

A pre- and post-intervention observational study was conducted to understand maternal and neonatal health service utilization rates before and after institutionalizing Vscan limited obstetric ultrasound services between July 2016 and June 2020. The actual data extraction was made from 1st August to 31st December 2020. The study was conducted in Amhara, Oromia, and Southern Nations, Nationalities and Peoples’ (SNNP) regions. These regions were selected due to the presence of Vscan limited obstetric ultrasound services in the selected health centers, for over two years. A health center is a public health facility within the primary healthcare system of Ethiopia, serving up to 25,000 people and has a mandate to provide promotive, preventive, curative, and rehabilitative outpatient care including basic laboratory and pharmacy services with a capacity for 10 beds for emergency and delivery services [12]. USAID funded the USAID Transform: Primary Health Care project (June 2016-June 2020) to support the MoH in line with its long-term goal of preventing child and maternal deaths (PCMD) [28]. To improve access to, and quality and equity of basic maternal and neonatal health services, the project, in collaboration with its technology partner General Electric Healthcare introduced Vscan access—a small portable ultrasound device—for obstetric scanning by trained mid-level healthcare providers [29]. The project strategizes to increase SBA through introducing ANC limited obstetric ultrasound services and improving the proper management of identified complications of pregnancies in referral health facilities, all of which contribute to maternal, fetal, and neonatal positive health outcomes [28, 30]. Vscan ultrasound machines with seed supplies were provided to each of the targeted 100 health centers after successfully providing basic limited ultrasound classroom and practical hands-on training for 10 days. The trainees were 219 mid-level healthcare providers who lacked knowledge and skills on the technology [31]. In addition, the training was supplemented with three sessions of monthly coaching, each lasting for two days, and the provision of virtual real-time feedback. Service initiation was supported through awareness creation and dissemination of information on ultrasound service availability at the health center level using all community engagement platforms including pregnant women conferences, women development army meetings, and house to house visits by health extension workers [28]. To ensure the quality of ultrasound services, a continuous mentorship was carried out by government and project staff. Pregnant women with detected abnormalities during scanning were referred to nearby hospitals for confirmation of diagnoses and further care. The number of women that received ultrasound scanning services during the first, second, third, or more trimester periods within the two years after the introduction of the services were 10,186, 2,974, and 1,509, respectively. Based on the 2007 national census, the projected population of the residents of targeted areas were 1.10 million in the year 2017. At the endpoint (2020), there were about 1.19 million people living within the study areas. Of these, the estimated number of pregnant women eligible for maternal and neonatal health services for the year 2020 were 40,506 (3.4%). The majority (13/30) of the health centers were enrolled from within the Oromia Region. On average, each health center is located 58.6 kilometers away from a referral receiving hospital (Table 1). The sample size was determined using the rule of thumb recommendation of The Aga Khan Foundation (1997) [32]. Thirty health centers were sampled i.e., 30% of the 100 health centers. The three regions were selected based on the accessibility and functionality of the ultrasound services during the time of data collection. Finally, a simple random sampling technique was applied to identify individual facilities. Three supervisors and 30 data collectors who are health science professionals were recruited from the targeted three regions. A two-day training on the objectives of the study, data collection techniques, ethical principles, and field pretesting was carried out. The data were extracted from a routine health information management system (HMIS) database using a pre-tested tool. To ensure the quality of data, three trained supervisors with master’s degrees in public health were deployed in the field and provided close technical support, with feedback given daily to the data collectors. The supervisors were responsible for checking and rechecking the collected data for completeness and consistency. The dependent variables were summary aggregated continuous data [33] of ANC1, ANC4, SBA, and PNC service reports. The independent variables were years of service. The data were entered and cleaned using Microsoft Excel 2016 and exported to SPSS V25 for descriptive and inferential analysis. The service utilization coverages were compared based on institutionalization of Vscan limited obstetric ultrasounds using 1,440 aggregate data collected from the 30 health centers (S1 File). In addition, for this study, the steps and procedures of Ross et al., (2013) were adopted [14]. The results of the statistical tests were presented using tables and graphs. To analyze F tests (one-way analyses of variance, ANOVA), the data violated the assumption of homogeneity of variances of a parametric test using Shapiro-Wilk test of normality P<0.05 (S2 File). Hence, the Kruskal-Wallis H test or a ‘one-way ANOVA on ranks’ which is an equivalent non-parametric test was employed to determine statistically significant differences between four groups of independent variables i.e., years of service. The statistical differences were claimed at P<0.05. However, the investigators maintained and ensured the following assumptions of the Kruskal-Wallis H test: (1) the dependent variables (ANC, SBA, and PNC) are interval data, (2) the independent variable has four categories, (3) there was no relationship between observations in each group, and (4) the distribution of scores in each group were not identical [28]. Finally, a statistical analysis was employed to compare data from twenty-four months (2017 and 2018) preceding the introduction of Vscan limited obstetric ultrasound services and twenty-four months (2019 and 2020) following the intervention. The mean rank monthly first ANC, fourth ANC, SBA, and PNC were compared before and after ultrasound services were initiated using a nonparametric test called the Kruskal-Wallis H test. Post hoc analysis using the KW-ANOVA H mean rank test was conducted with a Bonferroni correction applied. A statistical test result with a P-value of <0.0125 indicated the presence of a significant difference between service coverages over four years on ANC1, ANC4, SBA, and PNC.

Matériaux

Innovations

The study conducted in Ethiopia aimed to improve access to maternal health services by institutionalizing limited obstetric ultrasound services. The study found that the introduction of Vscan limited obstetric ultrasound services by trained mid-level providers at primary healthcare centers led to increased utilization of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) services.

The key findings of the study are as follows:

1. Antenatal Care (ANC): The introduction of limited obstetric ultrasound services resulted in a statistically significant increase in the mean rank of first ANC visits and fourth ANC utilization. This indicates that more pregnant women sought ANC services after the implementation of ultrasound services.

2. Skilled Birth Attendance (SBA): The study showed a statistically significant positive difference in the mean rank of skilled birth attendance after the introduction of ultrasound services. This suggests that more women opted for skilled delivery with the presence of ultrasound services.

3. Postnatal Care (PNC): The utilization of postnatal care services also showed a statistically significant increase after the implementation of limited obstetric ultrasound services. This indicates that more women accessed postnatal care for themselves and their newborns.

Based on these findings, the study recommends scaling up the institutionalization of limited obstetric ultrasound services and conducting further comparative studies to confirm causality and assess the effects on maternal and perinatal outcomes. The introduction of ultrasound services by trained mid-level providers at primary healthcare centers has the potential to improve access to ANC, SBA, and PNC services, ultimately contributing to positive maternal and neonatal health outcomes.

AI Innovations Description

The recommendation from the study is to institutionalize limited obstetric ultrasound services in order to improve access to maternal health. The study found that the introduction of limited obstetric ultrasound services by trained mid-level providers at primary healthcare centers in Ethiopia led to increased utilization of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) services. The study suggests scaling up the institutionalization of limited obstetric ultrasound services and conducting further comparative studies to confirm causality and assess effects on maternal and perinatal outcomes. This recommendation is based on the positive impact observed in terms of increased utilization of essential maternal health services after the introduction of ultrasound services. The study was published in PLoS ONE, Volume 18, No. 2 in February of the year 2023.

AI Innovations Methodology

To simulate the impact of the recommendations mentioned in the abstract on improving access to maternal health, a methodology could be developed as follows:

1. Selection of study sites: Choose primary healthcare centers in regions of Ethiopia where limited obstetric ultrasound services are not currently available. These regions should have a similar demographic and healthcare context as the regions where the study was conducted.

2. Intervention implementation: Introduce limited obstetric ultrasound services by trained mid-level providers at the selected primary healthcare centers. Provide necessary training to the healthcare providers on the use of ultrasound equipment and interpretation of results. Ensure that the ultrasound services are integrated into the existing maternal health services.

3. Data collection: Collect data on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) service utilization before and after the introduction of limited obstetric ultrasound services. This data can be obtained through routine health information management systems, surveys, or interviews with healthcare providers and pregnant women.

4. Data analysis: Analyze the data to compare the utilization rates of ANC, SBA, and PNC services before and after the introduction of ultrasound services. Use statistical tests, such as the Kruskal-Wallis H test or ANOVA, to determine if there are statistically significant differences in service utilization.

5. Comparative study: Conduct a comparative study between the primary healthcare centers with ultrasound services and those without ultrasound services. Compare the utilization rates of ANC, SBA, and PNC services in these two groups to assess the impact of ultrasound services on service utilization.

6. Assess maternal and perinatal outcomes: Evaluate the effects of increased service utilization on maternal and perinatal outcomes, such as maternal mortality, neonatal mortality, and birth complications. Compare these outcomes between the primary healthcare centers with ultrasound services and those without ultrasound services.

7. Scaling up and policy recommendations: Based on the findings of the study, recommend the scaling up of limited obstetric ultrasound services in primary healthcare centers across Ethiopia. Provide policy recommendations to the Ministry of Health and other relevant stakeholders on the integration of ultrasound services into the maternal health system.

By following this methodology, researchers can simulate the impact of institutionalizing limited obstetric ultrasound services on improving access to maternal health in Ethiopia. The findings can provide valuable insights for policymakers and healthcare providers to make informed decisions regarding the implementation of ultrasound services in primary healthcare settings.

Auteurs et co-auteurs

Statistics:

Authors: 12

Identifiers:

DOI: 10.1371/journal.pone.0281626

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Female

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