Lessons learned on maternal pregnancy screening in low-resource settings

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Jun 07, 2021
By the Philips Foundation team
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The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation to help identify pregnancy outcome risks. An accurate estimate of the gestational age is essential to support appropriate interventions during pregnancy, labor and delivery. Routine diagnostic ultrasound also improves the detection of fetal abnormalities and detects multiple pregnancies. Despite the well-known benefits, diagnostic imaging is insufficiently available in many rural and remote areas in low resource settings. A shortage of ultrasound-trained physicians is one cause. Multiple access barriers for pregnant women are another; including awareness, distance to hospitals, and high out-of-pocket fees.

Several innovative models have been developed in recent years to address the various gaps in access to ultrasound. The availability of compact, portable, and digitally connected ultrasound equipment allows the introduction of models in which trained nurses or midwives get involved in ultrasound scanning, while being remotely supported by specialists in urban hospitals. Together with healthcare experts, NGOs and social entrepreneurs worldwide, Philips Foundation has been pioneering such task sharing model and explored its relative aspects, such as delivery, referral and income models, to enable access to ultrasound for antenatal care.

 

Philips Foundation believes it is essential to conduct joint research and share learnings to develop effective primary healthcare systems. In April 2021, several specialists gathered to talk about advancing maternal care and ultrasound screening of pregnant women in low resource communities, highlighting lessons learned and best practices. 

 

Key outtakes and learnings from this dialogue and recommendations to take forward have been shared below:

 

Building clinical evidence

 

Together with the renowned Aga Khan University, Philips Foundation is running a scientific study demonstrating that connected digital innovation across the referral chain can increase early antenatal care uptake and improve pregnancy outcomes. Led by Prof. Marleen Temmerman, Chair Department of Obstetrics & Gynecology at Aga Khan University Hospital and Director Centre of Excellence in Women & Child Health at Aga Khan University, the project takes place in 21 health facilities in Kenya.

We are trying to study feasibility, affordability, and sustainability of implementing the WHO’s advice to have at least one ultrasound before 24 weeks gestation in the real-life situation in Kenya

Prof. Marleen Temmerman

Chair Department of Obstetrics & Gynecology at Aga Khan University Hospital

Through in-person training, remote education, and real-time video collaboration, midwives can build the skills and confidence to perform routine basic obstetric screening. This allows them to provide better care and identify women with high-risk pregnancies for timely treatment at a proper healthcare center, giving women a far better chance of bringing a healthy child into the world. 

 

Next to midwives, Community Health Workers (CHWs) are involved in the project in order to start the conversation at the household level. The CHWs are trained to use a mobile app that allows them to register pregnant women, conduct an initial risk assessment and explain the importance of going to the primary care clinic for an ultrasound scan as part of their prenatal care plan. 

 

According to Prof. Temmerman, it’s not about whether midwives can do basic ultrasounds, as this is already known from other settings, including many developed countries. Instead, “we are trying to study feasibility, affordability, and sustainability of implementing the WHO’s advice to have at least one ultrasound before 24 weeks gestation in the real-life situation in Kenya.”

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While the ongoing study [1] does not have the scale to prove the effects on maternal and child mortality directly, it will measure the effect of the intervention on 17 health outcome indicators that will be strongly indicative for healthy pregnancy outcomes. These indicators range from quality of early identification and referral of at-risk pregnancies, utilization of antenatal care services, communication between health providers, patient satisfaction and birth preparedness, and acceptability of the referral set up by health workers and government stakeholders. 

 

However, positive health outcomes are only one part of the puzzle. 

 

Health economics and affordability

 

Apart from technical and clinical feasibility and health outcomes, the question about affordability and sustainable financial models around the proposed solution of decentralized ultrasound screening by midwives, is essential to address as well. Hence, Philips Foundation and Amref International University in Nairobi teamed up to look at economic barriers and financial stimulants. 

 

In the project period, over 1250 pregnant women were screened in 10 health facilities in Kajiado and Kisii counties in Kenya. The study identified women’s motivations to take up routine ultrasound screening and the willingness to pay for it. It was shown that by offering the ultrasound services at the primary care level as part of antenatal care provision, women’s uptake increased to 50% within the pilot sites, compared to less than 10% previously when the service was only offered at a higher-level hospital. Distance turned out to be a key determinant for service uptake, next to women’s education level and quality of patient care and privacy offered. 

 

It is essential to point out that increased awareness among women about the benefits of ultrasound immediately led to improved uptake of obstetric scans – this indicates that community-level awareness is an important factor in achieving the desired care-seeking behavior.

 

The study revealed a high willingness of women to pay a reasonable price for the service (in the study, it was priced at 5 USD), mainly for confirmation of gestational age, fetal position and fetal sex. A parallel project with PharmAccess – a non-profit organization with a focus on sustainable financing of small and medium-sized health facilities – in Africa, confirmed payment readiness and even showed that women were willing to use a digital form of savings and payment.

 

The study [2] also explored a potential income model for midwives. Currently, only 30% of the over 3000 nurse-midwives that graduate annually gets formerly employed. The estimate derives from Amref’s Kenya Innovative and Sustainable Solutions for Midwives Education and Employment (KISSMEE) initiative, empowering unemployed and underemployed midwives to apply their professional skills.

 

Our study extended the KISSMEE model by examining whether small business units of midwives could invest in training and ultrasound equipment and achieve an attractive payback time through the offered obstetric screening. It was concluded that this could not yet be realized in the facilities studied, mainly because the realized client flows were not yet high enough – caused by the fact that the study ran in the midst of the COVID-19 pandemic, which had a clear effect on visits to the facilities. However, if the influx of clients can be increased, the business model can be made sustainable. Alternatively, different ownership and income models could be explored.

 

The above-mentioned projects mainly focused on Kenya. To come to other insights, Philips Foundation also explored beyond these borders.

 

Operational learnings (from Uganda and Pakistan)

 

Unlike Kenya, Uganda already has a legal framework for midwives to perform basic screening in rural clinics. Imaging the World – an organization dedicated to increasing access to modern medical imaging technology in the most rural and resource-limited areas – has been working in Uganda for 12 years to develop a fully sustainable model for providing ultrasound services in rural areas.

Patient awareness and demand for ultrasound have increased – with prenatal visits and skilled deliveries at partner clinics increasing most significantly

Kristen DeStigter

Founder of Imaging the World

By training 350 midwives, Imaging the World has enabled over 400,000 decentralized pregnancy scans. This has accrued a wealth of experience: in proof of concept and by demonstrating favorable outcomes among other, to ensure the quality of care over time. These lessons could benefit other countries envisioning similar systemic change.

 

In the model, nurses and midwives are trained to perform and interpret pregnancy scans. The outcomes show that adequate training and supervision of nurses and midwives, combined with tele-ultrasound technology, ensure the highest quality results for rural patients. Images are sent securely over cellular networks for surveilled monitoring, safety peer review, and consultation. Capacity strengthening at higher levels of care ensures that referrals are well-managed. This set-up has proven to enable a sustained level of diagnostic quality and case management.

 

“The model has since reshaped rural healthcare in Uganda,” underlines Kristen DeStigter, founder of Imaging the World. “Patient awareness and demand for ultrasound have increased – with prenatal visits and skilled deliveries at partner clinics increasing most significantly.”

 

Through the support of the Philips Foundation, Imaging the World is now establishing a centralized ultrasound training facility in Kampala. This will further expand the volume and quality of capacity building for midwives and other health professionals from Uganda and beyond.   

 

Although a completely different setting, another excellent example of task sharing is our project with Pakistan-based and social enterprise doctHERs. In Pakistan, many high skilled female health professionals stop working after marriage, leading to a significant knowledge spill. 

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DoctHERs explores models in which these health professionals can continue to contribute their valuable skills while working from home. “Through telehealth constructs, they are connected to lower-level frontline health workers in the field to support them with diagnosis, prescription, referral and other professional consulting”, says Dr. Aleena Durrani, Regional Manager Corporate Health & Wellness at doctHERs. “It’s an example of sharing tasks among different healthcare levels, leading to a direct benefit for patients.”

 

In collaboration with the Philips Foundation, doctHERS is exploring several case studies to expand their healthcare model with portable ultrasound. For example, home-based doctors are connected to nurse-led clinics in large manufacturing facilities, where workers are offered a variety of health services, including antenatal pregnancy consultations.

 

System change – what is further needed

 

Projects like these in Kenya, Uganda and Pakistan help gather data, experience and evidence of models to create better-equipped healthcare systems for low-resourceresource settings globally. The data can be used to help set up a framework for government policies and guidelines.

 

Dr. Bashir M. Issak, Head of the Department of Family Health at the Kenya Ministry of Health, commented on the projects and what, in his view, would be needed to turn positive results from pilot projects into adoption at scale. Dr. Bashir stressed the importance of undisputed evidence from solid scientific studies and peer-reviewed publications.

 

“This is even more critical in antenatal pregnancy screening, as it is known that it is hard to demonstrate the direct impact on maternal mortality. Therefore, secondary indicator evidence needs to be solid,” Dr. Bashir said. “Next to clinical evidence, economic affordability is critical, especially in regions where many critical system improvements compete for scarce resources.”

 

This topic was also addressed by Dr. Matthijs Groot Wassink, Philips’s Ultrasound business lead for Access to Care and Obstetrics. Similar to the findings in the business study with Amref, he argued that implementation at scale is the key to realize sustainable business models based on low costs per scan and making initial investment barriers less relevant. He also commented on how technology itself can help enable aspects of system change. For example, adding artificial intelligence algorithms to the portable ultrasound system can support in securing accurate diagnosis and hence be part of securing quality in access to care models based on task sharing.

 

All participants in the panel agreed that enabling midwives to perform maternal ultrasound scanning is a viable and essential way to achieve the WHO guideline to have at least one scan during pregnancy in low resource settings. They also agreed that portable, connected ultrasound solutions can support the transition by easing the remote collaboration between midwives and specialists to support training, coaching, diagnosis and sustained quality assurance. Through its projects, Philips Foundation aims to contribute to the development of evidence-based models that are scalable in resource-constrained settings and enhance access to quality healthcare for all.

Next to clinical evidence, economic affordability is critical, especially in regions where many critical system improvements compete for scarce resources

Dr. Bashir M. Issak

Head of the Department of Family Health at the Kenya Ministry of Health

[1] The project has done a complete baseline analysis and is now in the first months of implementation. Full research results are expected by the end of the year.

[2] The study with Amref International University was captured extensively in a scientific publication in the Open Journal of Clinical Diagnostics.

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