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Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.ORCID iD: 0000-0003-3391-2308
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
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2018 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 12, article id e0208387Article in journal (Refereed) Published
Abstract [en]

Objectives: Implementation of ultrasound in antenatal care (ANC) in low-income countries has been shown to increase pregnant women’s compliance with ANC visits, and facilitate detection of high-risk pregnancies. In Rwanda, as in other low-income countries, access to ultrasound has increased significantly, but lack of training is often a barrier to its use. The aim of this study was to investigate Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

Methods: A cross-sectional questionnaire study was undertaken between November 2016 and March 2017, as part of the CROss Country UltraSound Study (CROCUS). Data were collected at 108 health facilities located in both rural and urban areas of Rwanda, including provincial, referral, district and private hospitals as well as health centres. Participants were obstetricians (n = 29), other physicians (n = 222), midwives (n = 269) and nurses (n = 387).

Results: Obstetricians/gynecologists/other physicians commonly performed ultrasound examinations but their self-rated skill levels implied insufficient training. Access to ultrasound when needed was reported as common in hospitals, but available to a very limited extent in health centres. The vast majority of participants, independent of health profession, agreed that maternity care would improve if midwives learned to perform basic ultrasound examinations.

Conclusions: Barriers to provision of high quality ultrasound services include variable access to ultrasound depending on health facility level and insufficient skills of ultrasound operators. Physicians in general need more training to perform ultrasound examinations. Implementation of a general dating ultrasound examination seems to be a relevant goal as most health professionals agree that pregnant woman would benefit from this service. To further improve maternity care services, the possibility of educating midwives to perform ultrasound examinations should be further explored.

Place, publisher, year, edition, pages
PUBLIC LIBRARY SCIENCE , 2018. Vol. 13, no 12, article id e0208387
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:umu:diva-154875DOI: 10.1371/journal.pone.0208387ISI: 000452204800030PubMedID: 30513102Scopus ID: 2-s2.0-85057761963OAI: oai:DiVA.org:umu-154875DiVA, id: diva2:1275104
Available from: 2019-01-04 Created: 2019-01-04 Last updated: 2019-09-24Bibliographically approved
In thesis
1. Health professionals’ experiences and views related to obstetric ultrasound in Rwanda and Vietnam
Open this publication in new window or tab >>Health professionals’ experiences and views related to obstetric ultrasound in Rwanda and Vietnam
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

Obstetric ultrasound has become an indispensable part of maternity care in high-income countries, where it is universally used for screening, diagnostic and surveillance purposes. In low-income countries, insufficient numbers of trained health professionals’ is commonly a barrier to obstetric ultrasound use. Globally, health professionals’ encounter complex clinical situations in which rapid technical improvements in fetal surveillance and pregnancy interventions are components that influence clinical decisions, thereby implicating maternal and fetal health outcomes.

Aims

The overall aim of this thesis was to explore health professionals’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects, in two low-to-middle-income countries with different characteristics, cultures, religions and health care systems.

Methods

Study I (Rwanda) and Study III (Vietnam) are based on focus group discussions in which data were analysed using content analysis. Study I included six focus group discussions with 23 midwives recruited from six different hospitals in the area of Kigali and in the Southern province. Study III included four focus group discussions with 25 midwives working at three different hospitals in the Hanoi area. Study II (Rwanda) and Study IV (Vietnam) are cross-sectional studies using descriptive statistics, Pearson’s chi-square test and logistic regression analyses. A questionnaire, including items based on the results from previous qualitative studies, was used as the data collection tool. For Study II, health professionals (midwives, nurses, obstetricians, other physicians; N=907) working at 108 health facilities representing all provinces of Rwanda were recruited. Study IV constituted a regional sample of 824 health professionals (midwives, obstetricians/gynecologists) working at 29 health facilities in urban, semi-urban and rural parts of Hanoi, Vietnam.

Main findings

Obstetric ultrasound was regarded as a highly valued tool for pregnancy management in Rwanda as well as in Vietnam (Papers I–IV). In Rwanda, access to ultrasound was described as poor, especially for women living in rural areas (Paper I). In contrast, access to obstetric ultrasound was described as being very high in all health facilities in urban, semi-urban and rural areas of Hanoi (Paper III & Paper IV). In Rwanda, if a pregnancy was considered normal, obstetric ultrasound was not routinely performed (Paper I), while pregnant women in Vietnam were reported as undergoing several further ultrasound examinations in addition to the three examinations recommended by the Ministry of Health (Paper III). Midwives in Rwanda expressed a need to be trained in ultrasound, particularly those working at health centres in rural areas where ultrasound was rarely available (Paper I). A majority of health professionals (91%) also agreed that maternity care in Rwanda would improve if midwives were qualified to perform basic ultrasound examinations (Paper II). Sub-optimal pregnancy management due to a lack of or insufficient ultrasound training was reported by health professionals in both Rwanda (65%; Paper II) and Vietnam (37%; Paper IV). The use of obstetric ultrasound without medical indication was described as a troubling phenomenon, especially in Vietnam, where participants also reported that pregnant women sometimes replaced antenatal care surveillancewith ultrasound examinations (Paper III).

Conclusion

Obstetric ultrasound plays a significant role in pregnancy management in Rwanda, although access varies significantly. The findings indicate that physicians in Rwanda are in need of additional formal ultrasound training in order to increase the quality of ultrasound surveillance and to improve maternal and fetal health outcomes. To increase ultrasound access for all pregnant women in Rwanda, midwives could potentially be trained to perform basic ultrasound examinations. In the Hanoi area of Vietnam, ultrasound is a well-integrated tool in pregnancy management and access was high. However, overuse and commercialisation of obstetric ultrasound examinations were described as common and need to be addressed to achieve adequate allocation of resources. The rapid development of technology in maternity care needs to be accompanied by medical guidelines stating the appropriate indications for ultrasound surveillance.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2019. p. 79
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2042
Keywords
Prenatal ultrasonography, pregnancy, midwife, obstetrician, health personnel, health professional, prenatal care, epidemiology, cross-sectional study, focus group discussion, qualitative content analysis, Rwanda, Vietnam
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:umu:diva-163509 (URN)978-91-7855-087-6 (ISBN)
Public defence
2019-10-18, Stora Hörsalen, 5B, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-09-27 Created: 2019-09-24 Last updated: 2019-09-24Bibliographically approved

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