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Health professionals’ experiences and views related to obstetric ultrasound in Rwanda and Vietnam
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.ORCID iD: 0000-0003-3391-2308
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 [en]
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: urn:nbn:se:umu:diva-163509ISBN: 978-91-7855-087-6 (print)OAI: oai:DiVA.org:umu-163509DiVA, id: diva2:1353748
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
List of papers
1. Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound
Open this publication in new window or tab >>Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound
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2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1350451Article in journal (Refereed) Published
Abstract [en]

Background: Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed.

Objectives: To explore Rwandan midwives’ experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

Methods: A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS).

Results: Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed.

Conclusions: Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda.

Keywords
Rwanda, nurse, midwives, ultrasonography, obstetrics, pregnant women
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-138408 (URN)10.1080/16549716.2017.1350451 (DOI)000406687700001 ()
Available from: 2017-08-23 Created: 2017-08-23 Last updated: 2019-09-24Bibliographically approved
2. Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study
Open this publication in new window or tab >>Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study
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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
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-154875 (URN)10.1371/journal.pone.0208387 (DOI)000452204800030 ()30513102 (PubMedID)2-s2.0-85057761963 (Scopus ID)
Available from: 2019-01-04 Created: 2019-01-04 Last updated: 2019-09-24Bibliographically approved
3. Suboptimal use of ultrasound examinations may result in underperformance of Vietnamese maternity care- A qualitative study of midwives’ experiences and views
Open this publication in new window or tab >>Suboptimal use of ultrasound examinations may result in underperformance of Vietnamese maternity care- A qualitative study of midwives’ experiences and views
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective

To explore Vietnamese midwives’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

 

Methods

Using a qualitative design, content analysis of focus group discussions with midwives (N=25) working at Departments of Obstetrics and Gynecology at three hospitals in urban, semi-urban and rural parts of Hanoi were performed. 

 

Results

Obstetric ultrasound was reported as being a highly valuable tool, although replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication was perceived as troubling. Participants generally viewed the fetus as a human being already at an early stage of pregnancy. However, when complications occurred, the pregnant woman’s health was mostly prioritized.

 

Conclusion

Although the use of ultrasound has many benefits during pregnancy, replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication is concerning and needs to be addressed. There is also a need to communicate the benefits of adequate antenatal care to pregnant women and caution about the non-beneficial use of repeated ultrasound examinations without medical indication. Additionally, non-medical ultrasounds consume limited healthcare resources and its use needs to be better regulated in Vietnam. 

Keywords
Ultrasonography Prenatal, Midwives, Vietnam, Maternal Health Services, Antenatal Care, Pregnant women
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:umu:diva-163479 (URN)
Funder
Västerbotten County CouncilForte, Swedish Research Council for Health, Working Life and Welfare, 2014-2672
Available from: 2019-09-23 Created: 2019-09-23 Last updated: 2019-09-24
4. Health professionals’ experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study
Open this publication in new window or tab >>Health professionals’ experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study
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2019 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, article id e031761Article in journal (Refereed) Published
Abstract [en]

Objectives: Obstetric ultrasound is an important part of antenatal care in Vietnam, although there are great differences in access to antenatal care and ultrasound services across the country. The aim of this study was to explore Vietnamese health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

Design: A cross-sectional questionnaire study was performed as part of the CROss Country UltraSound study.

Setting: Health facilities (n=29) in urban, semiurban and rural areas of Hanoi region in Vietnam.

Participants: Participants were 289 obstetricians/ gynaecologists and 535 midwives.

Results: A majority (88%) of participants agreed that ‘every woman should undergo ultrasound examination’ during pregnancy to determine gestational age. Participants reported an average of six ultrasound examinations as medically indicated during an uncomplicated pregnancy. Access to ultrasound at participants’ workplaces was reported as always available regardless of health facility level. Most participants performing ultrasound reported high-level skills for fetal heart rate examination (70%), whereas few (23%) reported being skilled in examination of the anatomy of the fetal heart. Insufficient ultrasound training leading to suboptimal pregnancy management was reported by 37% of all participants. ‘Better quality of ultrasound machines’, ‘more physicians trained in ultrasound’ and ‘more training for health professionals currently performing ultrasound’ were reported as ways to improve the utilisation of ultrasound.

Conclusions: Obstetric ultrasound is used as an integral part of antenatal care at all selected health facility levels in the region of Hanoi, and access was reported as high. However, reports of insufficient ultrasound training resulting in suboptimal pregnancy management indicate a need for additional training of ultraso

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
Keywords
prenatal ultrasonography, health personnel, obstetricians, midwives, prenatal care, pregnancy, Vietnam
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:umu:diva-163499 (URN)10.1136/bmjopen-2019-031761 (DOI)31548354 (PubMedID)
Funder
Västerbotten County CouncilForte, Swedish Research Council for Health, Working Life and Welfare, 2013-2699Swedish Research Council, 2014-2672
Available from: 2019-09-23 Created: 2019-09-23 Last updated: 2019-09-26Bibliographically approved

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