Opportunities and Challenges in Realizing Universal Access to Obstetric Ultrasound in Sub-Saharan Africa

The potential benefits of obstetric ultrasound have yet to be fully realized in sub-Saharan Africa (SSA), despite the region bearing the greatest burden of poor perinatal outcomes. We reviewed the literature for challenges and opportunities of universal access to obstetric ultrasound and explored what is needed to make such access an integral component of maternity care in order to address the massive burden of perinatal morbidity and mortality in SSA. Original peer-reviewed literature was searched in various electronic databases using a ‘realist’ approach. While the available data were inconclusive, they identify many opportunities for potential future research on the subject within the region that can help build a strong case to justify the provision of universal access to ultrasound as an integral component of comprehensive antenatal care

Opportunities and Challenges in Realizing Universal Access to Obstetric Ultrasound in Sub-Saharan Africa

The potential benefits of obstetric ultrasound have yet to be fully realized in sub-Saharan Africa (SSA), despite the region bearing the greatest burden of poor perinatal outcomes. We reviewed the literature for challenges and opportunities of universal access to obstetric ultrasound and explored what is needed to make such access an integral component of maternity care in order to address the massive burden of perinatal morbidity and mortality in SSA. Original peer-reviewed literature was searched in various electronic databases using a ‘realist’ approach. While the available data were inconclusive, they identify many opportunities for potential future research on the subject within the region that can help build a strong case to justify the provision of universal access to ultrasound as an integral component of comprehensive antenatal care

Reminder systems for self uterine massage in the prevention of postpartum blood loss

Background: Uterine massage may significantly reduce post partum blood loss and could be patient-driven.Objective: To assess the effectiveness of an alarm reminder system for self uterine massage in the prevention of post partum blood loss.Design: A random controlled trial.Setting: Meru District Hospital, Kenya.Subjects: One hundred and twenty seven (127) women were randomly assigned to a 15 minute alarm reminder system (71) and non-alarm (56) control arm during the fourth stage of labour.Results: Uterine massage compliance was better in the alarm group compared to the non-alarm group ( Average massage of seven and two in two hours respectively P-value <0.0001), however the difference in blood loss was not significant 45.6 ml (95% CI 43-46) vs 47.1 ml (95% CI 43-52)ml p-value 0.892.Conclusion: Uterine massage compliance is remarkably increased by the use of an alarm reminder

Scientific basis for standardization of fetal head measurements by ultrasound: a reproducibility study.

OBJECTIVE: To compare the standard methods for ultrasound measurement of fetal head circumference (HC) and biparietal diameter (BPD) (outer-to-outer (BPDoo) vs outer-to-inner (BPDoi) caliper placement), and compare acquisition of these measurements in transthalamic (TT) vs transventricular (TV) planes. METHODS: This study utilized ultrasound images acquired from women participating in the Oxford arm of the INTERGROWTH-21(st) Project. In the first phase of the study, BPDoo and BPDoi were measured on stored images. In the second phase, real-time measurements of BPD, occipitofrontal diameter (OFD) and HC in TT and TV planes were obtained by pairs of sonographers. Reproducibility of measurements made by the same (intraobserver) and by different (interobserver) sonographers, as well as the reproducibility of caliper placement and measurements obtained in different planes, was assessed using Bland-Altman plots. RESULTS: In Phase I, we analyzed ultrasound images of 108 singleton fetuses. The mean intraobserver and interobserver differences were < 2% (1.34 mm) and the 95% limits of agreement were < 5% (3 mm) for both BPDoo and BPDoi. Neither method for measuring BPD showed consistently better reproducibility. In Phase II, we analyzed ultrasound images of 100 different singleton fetuses. The mean intraobserver and interobserver differences were < 1% (2.26 mm) and the 95% limits of agreement were < 8% (14.45 mm) for all fetal head measurements obtained in TV and TT planes. Neither plane for measuring fetal head showed consistently better reproducibility. Measurement of HC using the ellipse facility was as reproducible as HC calculated from BPD and OFD. OFD by itself was the least reproducible of all fetal head measurements. CONCLUSIONS: Measurements of BPDoi and BPDoo are equally reproducible; however, we believe BPDoo should be used in clinical practice as it allows fetal HC to be measured and compared with neonatal HC. For all head measurements, TV and TT planes provide equally reproducible values at any gestational age, and HC values are similar in both planes. Fetal head measurement in the TT plane is preferable as international standards in this plane are available; however, measurements in the TV plane can be plotted on the same standards. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd

International standards for fetal brain structures based on serial ultrasound measurements from the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project.

OBJECTIVE: To create prescriptive growth standards for five fetal brain structures, measured by ultrasound, from healthy, well-nourished women, at low risk of impaired fetal growth and poor perinatal outcomes, taking part in the Fetal Growth Longitudinal Study (FGLS) of the INTERGROWTH-21st Project. METHODS: This was a complementary analysis of a large, population-based, multicentre, longitudinal study. We measured, in planes reconstructed from 3-dimensional (3D) ultrasound volumes of the fetal head at different time points in pregnancy, the size of the parieto-occipital fissure (POF), Sylvian fissure (SF), anterior horn of the lateral ventricle (AV), atrium of the posterior ventricle (PV) and cisterna magna (CM). The sample analysed was randomly selected from the overall FGLS population, ensuring an equal distribution amongst the eight diverse participating sites and of 3D ultrasound volumes across pregnancy (range: 15 - 36 weeks' gestation). Fractional polynomials were used to the construct standards. Growth and development of the infants were assessed at 1 and 2 years of age to confirm their adequacy for constructing international standards. RESULTS: From the entire FGLS cohort of 4321 women, 451 (10.4%) were randomly selected. After exclusions, 3D ultrasound volumes from 442 fetuses born without congenital malformations were used to create the charts. The fetal brain structures of interest were identified in 90% of cases. All structures showed increasing size with gestation and increasing variability for the POF, SF, PV and CM. The 3rd , 5th , 50th , 95th and 97th smoothed centile are presented. The 5th centile of POF and SF were 2.8 and 4.3 at 22 weeks and 4.2 and 9.4mm at 32 weeks respectively. The 95th centile of PV and CM were 8.5 and 7.4 at 22 weeks and 8.5 and 9.4mm at 32 weeks respectively. CONCLUSIONS: We have produced prescriptive size standards for fetal brain structures based on prospectively enrolled pregnancies at low risk of abnormal outcomes. We recommend these as international standards for the assessment of measurements obtained by ultrasound from fetal brain structures

Perspectives on the Practice of Vaginal birth after Caesarean Section in East Africa

Background: The increasing Caesarean section rates being observed in most facilities will ultimately result in a larger proportion of women with previous scar. Choices need to be made by both the patient and the health worker between attempted vaginal birth after Caesarean section (VBAC) and Elective Repeat Caesarean section (ERCS). Both practices are associated with perinatal risks and benefits that call for certain objectivity and prudence in decision making especially where resources are scarce. Objective: To determine perceptions on the practice of vaginal birth after Caesarean section among maternity service providers in East Africa. Design: A semi-qualitative cross sectional survey using self administered questionnaires. Setting: The study was undertaken among delegates attending a regional obstetrics and gynaecology conference in Mombasa, Kenya. Subject: Sixty three consenting delegates were interviewed Results: A majority (69.8%) of the respondents were consultants and midwives working in government facilities. Fifty eight out of the 63 respondents offered VBAC in their institutions despite acknowledging sub-optimal antenatal preparation. The main concerns identified were; deficiencies in healthcare delivery systems, inadequate human resources, lack of unit guidelines, inappropriate maternal education and inappropriate foetal monitoring tools. Conclusion: The practice of vaginal birth after Caesarean section was perceived to be sub-optimal with many existing deficiencies that need urgent action to ensure the safety of mothers and newborns. We therefore recommend that unless these concerns raised by maternity providers are addressed then the practice of VBAC in the region should not be encouraged.East African Medical Journal Vol. 87 No. 8 August 201

Utility of the short form (SF)-36 health related quality of life questionnaire as a measure of outcome among contraceptive users

Background: Health related quality of life tools have been utilized in assessing many medical conditions; however, there has been minimal use in reproductive health research locally.Objectives: To evaluate the utility of the short form (SF)-36 health survey questionnaires among contraceptive users.Methodology: This was a cross sectional study which formed part a longitudinal observation study conducted over a 6-month period at the Aga Khan University Hospital and the Family Health Options clinics in Nairobi, Kenya among users of depot medroxyprogesterone acetate for contraception. The main outcome measures were the eight scales within the SF 36 health profile. Kline’s criterion of 0.4 was used to test for inter scale correlations while the internal consistency was measured by the Cronbach’s alpha using the Nunnally’s criterion of 0.7.Results: The SF-36 questionnaire was administered to 107 consenting clients. The mean scores for the eight scale SF-36 questionnaire were: physical functioning 81.4 (SD 22.4), social functioning 77.3 (SD 19.4), role limitation attributed to physical problem 81.6 (SD 31.6), role functioning attributed to emotional problems 76.3 (SD 35.5), energy and fatigue 66.9 (SD 16.4), mental health 71.4 (SD 17.5), general health 74.1 (SD 14.5) and pain 79.7 (SD 22.1). The SF-36 questionnaire satisfied rigorous psychometric criteria for reliability and internal consistency for 6 of the 8 scales. The item scale correlation persistently exceeded 0.4 for all variables.Conclusion: These results provide support for use of SF-36 and other medical outcome survey tools as potential measures of quality of life among contraceptive users in the local population.Keywords: Health related quality of life, contraceptives, depot-medroxyprogesterone acetate, RAND SF-3

Image scoring system for umbilical and uterine artery pulsed wave Doppler ultrasound measurement.

Objectives To develop an objective image‐scoring system for pulsed‐wave Doppler measurement of maternal uterine and fetal umbilical arteries, and evaluate how this compares with subjective assessment. Methods As an extension to the INTERGROWTH‐21st Project, we developed a scoring system based on six predefined criteria for uterine and umbilical artery pulsed‐wave Doppler measurements. Objective evaluation using the scoring system was compared with subjective assessment which consisted of classifying an image as simply acceptable or unacceptable. Based on sample size estimation, a total of 120 umbilical and uterine artery Doppler images were selected randomly from the INTERGROWTH‐21st image database. Two independent reviewers evaluated all images in a blinded fashion, both subjectively and using the six‐point scoring system. Percentage agreement and kappa statistic were compared between the two methods. Results The overall agreement between reviewers was higher for objective assessment using the scoring system (agreement, 85%; adjusted kappa, 0.70) than for subjective assessment (agreement, 70%; adjusted kappa, 0.47). For the six components of the scoring system, the level of agreement (adjusted kappa) was 0.97 for anatomical site, 0.88 for sweep speed, 0.77 for magnification, 0.68 for velocity scale, 0.68 for image clarity and 0.65 for angle of insonation. Conclusion In quality assessment of umbilical and uterine artery pulsed‐wave Doppler measurements, our proposed objective six‐point image‐scoring system is associated with greater reproducibility than is subjective assessment. We recommend this as the preferred method for quality control, auditing and teaching