Empowering midwives to deliver community-based ultrasound screening

Study to explore sustainable decentralization of obstetric ultrasound screening to primary healthcare facilities through an income-based model for midwives

About

The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks of pregnancy to help identify pregnancy outcome risks. However, diagnostic imaging is insufficiently available in rural and remote areas in low-resource settings. In several projects, Philips Foundation explores models to increase access to ultrasounds by task-sharing between locally operating midwives supported by sonographers at distance via telehealth.

In this project with Amref International University, we tested the viability of a sustainable income model for a social franchise of midwives offering pregnancy screening in primary healthcare facilities.

Partners

How

The main goals of the pilot was to analyze antenatal women's willingness to pay for an ultrasound, to examine the ability of midwives to become social entrepreneurs, and to test the viability of the proposed business case. To this end, the following intervention and activities were conducted:

The project was fully aligned with and endorsed by key stakeholders, including the Society of Radiography in Kenya, the Nursing Council of Kenya, the Midwives Association of Kenya, and the County Governments.
42 midwives were trained successfully on two standardized and blended learning modules. 10 sonographers were involved in the training, and subsequently supported the midwives in conducting and interpreting the screenings. 950 pregnant women were screened for free during this training. To date, a total of 67 midwives have been trained. The ability of midwives to correctly conduct obstetric ultrasound screening was assessed and rated by radiologists.
2-5 midwives were grouped into business units (BUs) to create functional teams in 10 health facilities in 2 counties in Kenya (Kadjiado and Kisii). Each business unit was mentored by a radiographer. Each business unit received a point-of-care ultrasound device, and a connection to a digital platform which enabled remote collaboration with professional sonographers. County governments allowed the midwives to charge KSh500 per session. Midwives’ monthly incentive was performance based.
The study identified women’s motivations and barriers to take up routine ultrasound screening and their willingness to pay for it.

Based on these findings, the study explored a potential income model for midwives.

Results

The training, implementation, and study of the project were successfully completed. Over the project period, more than 1,200 paid ultrasound screenings were conducted. The study confirmed women’s willingness to pay for the service, hence confirming the principal foundation for an income-based scalable model. Whether the length of time before they break even is sufficiently short to enable the midwife-based ownership model will strongly depend on utilization flows. The project led to valuable new insights that were disseminated through several peer reviewed publications, conferences and online webcasts.

Learnings and next steps

Midwives were able to learn the essential skills for obstetric ultrasound screening, as confirmed by sonographers and through self-rating. The midwives’ competencies increase over time. Training, mentorship and coaching are critical drivers in the decentralisation of ultrasound screening.
Women are willing to pay for obstetric ultrasound screening. Women’s education level, the point in pregnancy and distance to the point of care were the most critical determinants of undertaking obstetric ultrasound screening service. Mothers paid for the service mostly to confirm the pregnancy, foetal position and foetal gender.