A low-cost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural uganda

Background: In June of 2010, an antenatal ultrasound program to perform basic screening for high-risk pregnancies was introduced at a community health care center in rural Uganda. Whether the addition of ultrasound scanning to antenatal visits at the health center would encourage or discourage potential patients was unknown. Our study sought to evaluate trends in the numbers of antenatal visits and deliveries at the clinic, pre-and post-introduction of antenatal ultrasound to determine what effect the presence of ultrasound at the clinic had on these metrics. Methods and Findings: Records at Nawanyago clinic were reviewed to obtain the number of antenatal visits and deliveries for the 42 months preceding the introduction of ultrasound and the 23 months following. The monthly mean deliveries and antenatal visits by category (first visit through fourth return visit) were compared pre-and post-ultrasound using a Kruskal-Wallis one-way ANOVA. Following the introduction of ultrasound, significant increases were seen in the number of mean monthly deliveries and antenatal visits. The mean number of monthly deliveries at the clinic increased by 17.0 (13.3-20.6, 95% CI) from a pre-ultrasound average of 28.4 to a post-ultrasound monthly average of 45.4. The number of deliveries at a comparison clinic remained flat over this same time period. The monthly mean number of antenatal visits increased by 97.4 (83.3-111.5, 95% CI) from a baseline monthly average of 133.5 to a post-ultrasound monthly mean of 231.0, with increases seen in all categories of antenatal visits. Conclusions: The availability of a low-cost antenatal ultrasound program may assist progress towards Millennium Development Goal 5 by encouraging women in a rural environment to come to a health care facility for skilled antenatal care and delivery assistance instead of utilizing more traditional methods.

In June 2010 a program was put in place by the NGO Imaging the World (ITW; www.imagingtheworld.com) to provide access to basic antenatal ultrasound at the Nawanyago community level III health care centre (HC III) in Uganda. Women are offered an ultrasound scan at the first ANC visit, and again at 32 weeks gestation. If there is a clinical indication (infections, hemorrhage, pain), then scans are done at other ANC visits as well. With a population of 23,000, the health care needs of Nawanyago sub-county in Kamuli District are served by this private HC III (under the jurisdiction of the Diocese of Jinja) in addition to a government HC III in Bupadhengo, 4 km away. Services offered at the clinic by two midwives with many years of experience include antenatal care visits, testing and treatment for co-morbidities of pregnancy (malaria, worms, anemia, hypertension, HIV, syphilis, etc.), and skilled routine vaginal deliveries (including breech deliveries). Most pregnant women requiring urgent or emergent care, including C-section, are referred to Kamuli Mission Hospital, a distance of 24 km from Nawanyago HC III. To address the human resource problem of few trained sonographers in low resource settings, scanning protocols have been developed by ITW that rely solely on the use of surface anatomy landmarks. The ultrasound probe is passed across the pregnant abdomen in a series of six prescribed sweeps acquiring a series of static images. A low-frequency curved transducer is used to obtain the sweeps with the pregnant patient in a supine position, having a full bladder. This volume of images can be scrolled through by the reviewer like a short video. An initial feasibility study confirmed that the images obtained with this protocol are of diagnostic quality [24]. Low cost, portable ultrasound machines are utilized. The machines have been preconfigured to provide three presets to optimize image quality for three BMI categories: small, medium, or large. The acquired images are de-identified and stored locally on a laptop computer before being compressed and transmitted digitally via cell phone modem to a remote internet server where they can then be accessed by a credentialed reviewer, either in country or abroad, for interpretation. An abbreviated report of the findings is sent via SMS to the nurse midwife’s cell phone with the full report sent by email. Women are thus able to receive the initial results of their scan prior to the end of the visit, and they are given recommendations for the next steps in their care. The fetal gender is not disclosed. The full program methodology has been previously reported [25]. Two midwives from Nawanyago HC III were trained in the protocol by ITW over a 3-day period. The educational program included classroom and hands-on teaching with assessment of competency. Final interpretations were given by credentialed sonographers from Kamuli Mission Hospital, the primary referral hospital for Nawanyago HC III. During the period of the study, quality assurance for both image quality and accuracy of interpretations was performed remotely by ITW. Although Ugandan ITW personnel made weekly site visits, foreign ITW volunteers re-visited the site only a total of 6 days during the pilot study period. A small fee (approximately $2 USD) was charged per exam to help with the clinic operating costs and to remunerate the interpreters. The fee was determined by the clinic based on what was felt to be affordable to the local community. The revenue generated allows the program to be financially self-sustaining. All patients were able to afford the fee for the ultrasound examination. Ultrasound can diagnose many of the most common causes of maternal and neonatal mortality including multiple gestations, sequelae of abortion, causes of obstructed labor, and specific causes of maternal hemorrhage such as placenta previa [9], and this is the focus of the ITW program. The implemented scanning protocols allow for reliable identification of fetal presentation and number as well as placental position. Early identification of high-risk pregnancies allows clinic staff to recommend delivery with skilled care at the clinic instead of at home or timely referral to the district hospital in Kamuli for a higher level of obstetric care. All patients who were referred to Kamuli Mission Hospital for definitive diagnosis and treatment made the journey. Originally, the ultrasound scanning protocols were evaluated through an IRB-approved concordance study that assessed the effectiveness of the ITW methods as previously reported [25]. While evaluating the data we observed certain clinical trends in the ANC visit and delivery data that merited further consideration. Using the existing dataset, we developed a retrospective study protocol to evaluate the “magnet effect” associated with the introduction of antenatal ultrasound scanning at the HC III. Following introduction of the ultrasound program in June of 2010, records at the HC III, including number of ANC visits and deliveries, were collected through April of 2012. Historical control data obtained from January 2007 through the introduction date were used as comparator. Data included the 41 months preceding the introduction of the ultrasound program and the 23 months following. For the historical control, only aggregated, clinic-level data was available. This constituted data available from clinic records that are updated by clinic staff and kept on hard copy at the clinic in a secure location. This data is also reported to the Diocese of Jinja and the Uganda Ministry of Health and is publicly available in aggregated form. The available information included: the number of births at the clinic per month, the number of first ANC visits per month, the number of second ANC visits per month, the number of third ANC visits per month and the number of fourth ANC visits per month. All clinic records were subsequently audited by an independent research associate from the Makerere University School of Public Health in Kampala and found to be consistent with the numbers provided to the research team by clinic staff. Statistical analysis was performed using SAS version 9.3 (SAS Inc., Cary, NC, USA). For the historical control data, for both deliveries and ANCs were available as aggregated monthly counts. For comparability, the data collected after the introduction of ultrasound were collapsed into aggregated monthly counts as well. The number of ANCs was examined both categorized by number of visit (first time ANC visit through fourth return ANC visit) and in sum as total number of ANCs. Results were summarized descriptively using the number of observations, mean, standard deviation (SD), 95% confidence interval (CI) for the mean, median, minimum, and maximum values. Prior to statistical testing, the data were assessed for normality by visual inspection of plots and formally by the Shapiro-Wilk’s test. In all cases, the data were not normally distributed; therefore non-parametric statistical analyses were used. A Kruskal–Wallis one-way analysis of variance (KW-ANOVA) by ranks was conducted to compare the data from the pre-ultrasound time period to the post-ultrasound time period. Due to the retrospective nature of the study, the validity of the historical control was assessed. A KW-ANOVA was conducted to determine if the data were consistent over time prior to the introduction of ultrasound, and if the data were consistent over time after the introduction of ultrasound. Each model included one factor for year. If the model indicated that the data were consistent over time prior to the introduction of ultrasound (i.e., year was not a significant factor) and the data were consistent after the introduction of ultrasound, it could be interpreted that no confounding event occurred prior to or after ultrasound introduction (June 2010) to alter the number of deliveries or ANC visits. Additionally, the number of deliveries during the months from July 2008 to June 2012 from a nearby (4 km) government facility (Bupadhengo HCIII) was available. These data were compared pre-June 2010 to post June-2010. If the number of deliveries remained stable over time, it would further support the assumption that no confounding event occurred in the general Nawanyago area in June 2010 that altered the number of deliveries. Investigational Review Board (IRB) approval was obtained from the Mengo Hospital Research Review Committee, (IRB title Evaluation of Simple Ultrasound Protocols for Improving Access to Ultrasound in Low Resource Settings, study number 013/05–10). Written informed consent was obtained from all study participants with appropriate translation and literacy resources provided as necessary. The consent form and process were approved by the IRB. All ultrasound images and patient records were de-identified with the patients receiving an “ITW number” that functioned as the medical record number. Patient identifying information was kept in a secure location at Nawanyago HC III. All Data were coded anonymously for analysis. Ultrasound results were recorded in the Ugandan Ministry of Health Maternal Passport, which is distributed by the HC III to all pregnant patients. For ethical reasons, fetal gender determination is not performed and the program is periodically audited to ensure compliance with this requirement.

N/A

• Dima Health