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

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.