1. Introduction
1.1. Importance of Ultrasound in Obstetric Care
The critical contribution of obstetric imaging is central to reducing maternal and perinatal morbidity and mortality
| [1] | Stefanovic V. Role of obstetric ultrasound in reducing maternal and neonatal mortality in developing countries: from facts to acts. Donald School Journal of Ultrasound in Obstetrics and Gynecology. 2020; 14(1): 43-9. https://doi.org/10.5005/jp-journals-10009-1617 |
[1]
. The evolution of ultrasound in medicine has greatly revolutionized healthcare worldwide, especially in the field of Obstetrics and Gynecology
| [2] | Adekanmi A. J, Morhason-Bello IO, Atalabi O. M, Adedokun BO, Adeniji-Sofoluwe A. A, Marinho AO. Misconception About Ultrasound Among Nigerian Women Attending Specialist and Tertiary Health Institutions in Ibadan. Trop J Obstet Gynaecol, 2012; 29(2). |
[2]
. Ultrasound is well established as a safe tool, and it is often the first imaging modality employed in the screening, investigation, and treatment of conditions in Obstetrics and Gynecology
.
The International Federation of Gynecology and Obstetrics (FIGO) recommends two ultrasound examination services for all pregnant women
| [4] | Figo Working Group on Best Practice in Maternal-Fetal Medicine, International Federation of Gynecology and Obstetrics. Best practice in maternal-fetal medicine. Int J Gynaecol Obstet. (2015) 128(1): 80-2. https://doi.org/10.1016/j.ijgo.2014.10.011 |
[4]
. Similarly, in 2016, the World Health Organization (WHO) recognized the benefits of offering at least one antenatal ultrasound scanning service, before 24 weeks of gestation, for all pregnant women
| [5] | World Health Organization. Intrapartum Care for a Positive Childbirth Experience. Geneva: World Health Organization; 2018. |
[5]
.
1.2. Burden of Delays in the Detection of High-risk Pregnancy Conditions Until Delivery
High-risk pregnancies are better managed when diagnosed early, which ensures adequate preparations, prompt referral, and expert care. Outcomes are usually better in such settings. Conditions like multiple gestation, placenta previa, vasa previa, fetal viability, pregnancy location, and abnormal presentation can be easily diagnosed with obstetric imaging. Some patients do not have access to ultrasound imaging in pregnancy, either due to a lack of antenatal care or the unavailability of obstetric imaging. In a study of recently diagnosed hundred twin pregnancies in South Africa, 25% were diagnosed at delivery due to a lack of imaging
. Obstetric ultrasound has become an indispensable part of ANC around the world
| [7] | Holmlund S, Ntaganira J, Edvardsson K, Lan PT, Semasaka Sengoma JP, Åhman A, Small R, Mogren I. Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives’ experiences and views of obstetric ultrasound. Global health action. 2017 Jan 1; 10(1): 1350451. https://doi.org/10.1080/16549716.2017.1350451 |
[7]
.
1.3. Limited Access to Ultrasound in LMICs and Its Consequences
In low and middle-income countries there are grossly inadequate machines and qualified sonographers; high-risk conditions during pregnancy might be undetected until delivery, creating a missed opportunity for prenatal diagnosis that could generate information to enhance prompt management of life-threatening conditions
| [8] | Papp Z and Fekete T. The evolving role of ultrasound in obstetrics/gynecology practice. Int J Gynaecol Obstet. (2003) 82(3): 339-46. https://doi.org/10.1016/S0020-7292(03)00224-8 |
| [9] | Shah SP, Johnston V, Allotey P, Mulholland K and Markovic M. Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008. BMC Int Health Hum Rights. (2009) 9: 1-6. https://doi.org/10.1186/1472-698X-9-4 |
[8, 9]
. A study across 56 tertiary centres in Nigeria showed that Only 10% had fully functional ultrasound service that catered for over half of their clients. Others either did not have any ultrasound scan machines and or lacked any trained personnel in ultrasound within the department
| [10] | Enabudoso E, Akinmoladun J, Igbarumah S, Raji HO, Njoku AI, Awowole I, Ogbebor O, Ikubor J, Aliyu L. A study to evaluate the practice and training in Obstetric ultrasound at accredited Obstetrics and Gynaecology training institutions in Nigeria. Nigerian Medical Journal. 2022; 63(1): 29-34. |
[10]
. Delays in making prenatal ultrasound based diagnosis can be disastrous especially in low resource settings without the capacity to manage such, this poses great burden to both maternal and perinarinal morbidity and mortality. There is therefore a need to bridge the gap in access to obstetric scans in low-resource settings. Hence, the task-shifting and training approach is an option to explore.
1.4. Task-Shifting and Training as Implementation Strategies
The World Health Organization (WHO) recommends task shifting as one strategy to strengthen and expand the health workforce
| [11] | World Health Organization. Task shifting: Global Recommendations and Guidelines. Geneva: World Health Organization; 2008. |
[11]
. By task shifting, specific tasks are moved from highly qualified health workers to health workers with shorter training and fewer qualifications in order to increase the efficiency of available human resources for health
| [12] | World Health Organization. Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. World Health Organization; 2007. |
| [13] | World Health Organization. Delivering Quality Health Services: A Global Imperative. OECD Publishing; 2018. |
[12, 13]
. This model, endorsed by the World Health Organization, has become increasingly relevant in LMIC settings where the availability of specialists is limited.
By redistributing roles, task shifting enhances efficiency, expands service coverage, and ensures that essential interventions—such as maternal and newborn care, family planning, and basic diagnostic procedures like Ultrasound scans are more widely accessible. In obstetrics, for example, trained midwives and general physicians can effectively provide antenatal care, contraceptive services, and emergency and obstetric interventions under appropriate supervision
| [11] | World Health Organization. Task shifting: Global Recommendations and Guidelines. Geneva: World Health Organization; 2008. |
| [12] | World Health Organization. Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. World Health Organization; 2007. |
[11, 12]
.
Progress in technology has advanced the development of portable, easy-to-use, and affordable ultrasound devices that allow imaging at the patient’s bedside
| [14] | Frija G, Blažić I, Frush DP, Hierath M, Kawooya M, Donoso-Bach L, et al. How to improve access to medical imaging in low- and middle-income countries? E Clinical Medicine. 2021. 17; 38: 101034. https://doi.org/10.1016/j.eclinm.2021.101034 |
[14]
. Point-of-care ultrasound (POCUS) is a promising task-shifting approach moving sonographic imaging from radiologists/specialists to frontline healthcare workers
. Task shifting, the concept of rational use of lower cadre workers to perform specific tasks hitherto meant for more medically qualified personnel for more efficient use of human capital for health, has been promoted as a useful option for the provision of POCUS in low-resource settings
| [11] | World Health Organization. Task shifting: Global Recommendations and Guidelines. Geneva: World Health Organization; 2008. |
| [12] | World Health Organization. Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. World Health Organization; 2007. |
[11, 12]
. The Edo state government adopted a task-shifting approach to train health workers at the grassroots level to increase the workforce to carry out obstetric POCUS.
1.5. Point-of-Care Ultrasound as a Solution for Maternal-Fetal Health
Point-of-care ultrasound (POCUS) in obstetrics describes the concept of using ultrasound by trained medical/health personnel to make real-time diagnostic and management decisions at the bedside
| [17] | Reynolds TA, Amato S, Kulola I, Chen CJ, Mfinanga J, Sawe HR. Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania. PLoS One. 2018; 13(4): e0194774. https://doi.org/10.1371/journal.pone.0194774 |
[17]
. POCUS improves health outcomes by timely diagnosis, which results in expedited clinical decision-making, and reduces lengths of hospital stays, prompt referrals, and cuts costs, as well as limits challenges in the setting of limited human resources
| [17] | Reynolds TA, Amato S, Kulola I, Chen CJ, Mfinanga J, Sawe HR. Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania. PLoS One. 2018; 13(4): e0194774. https://doi.org/10.1371/journal.pone.0194774 |
| [18] | Aloysius G. M, Geoffrey E., Nassanga R. and Kiguli-Malwadde E. Point of care obstetric ultrasound training for midwives and nurses: implementation and experiences of trainees at a rural based hospital in Sub-saharan Africa: a qualitative study. BMC Research Notes (2023) 16: 287 https://doi.org/10.1186/s13104-023-06569-8 |
| [19] | Dalmacion GV, Reyles RT, Habana AE, et al. Handheld ultrasound to avert maternal and neonatal deaths in 2 regions of the Philippines: an iBuntis_ intervention study. BMC Pregnancy Childbirth. 2018; 18(1): 32. https://doi.org/10.1186/s12884-018-1658-8 |
[17-19]
. A study conducted in three regions of Ethiopia found that introducing ultrasound services at the primary health care level, by mid-level health professionals, led to an increase in both antenatal and postnatal care utilization
| [20] | Abawollo HS, Tsegaye ZT, Desta BF, Beshir IA, Mengesha BT, Guteta AA, et al. Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study. BMC Pregnancy Childbirth. (2022) 22(1): 368. https://doi.org/10.1186/s12884-022-04703-1 |
[20]
. The use of ultrasound in developing countries is limited by several factors, such as culture, religion, illiteracy, attitude, accessibility, and the high cost of ultrasound equipment; the fee for using ultrasound in a private clinic; the lack of trained sonographers or physicians; and the skill required to perform the examinations
| [21] | Wanyonyi SZ, Mariara C, Vinayak S, Stones W. Opportunities and challenges in realizing universal access to obstetric ultrasound in sub-Saharan Africa. Ultrasound Int Open. (2017) 3(02): E52-9. https://doi.org/10.1055/s-0043-103948 |
[21]
. Combining task shifting and point-of-care diagnostics can overcome some of these shortcomings.
1.6. Knowledge Gap and Study Aims
Maternal and perinatal morbidity and mortality is still a challenge. Prompt prenatal diagnosis with ultrasound imaging is an approach to reduce this scourge. However, the lack of infrastructures for ultrasound scan and specialist sonologists is a glaring challenge in low resource settings
| [10] | Enabudoso E, Akinmoladun J, Igbarumah S, Raji HO, Njoku AI, Awowole I, Ogbebor O, Ikubor J, Aliyu L. A study to evaluate the practice and training in Obstetric ultrasound at accredited Obstetrics and Gynaecology training institutions in Nigeria. Nigerian Medical Journal. 2022; 63(1): 29-34. |
[10]
. The Edo state government had keyed in to the POCUS approach at the grass root health care level. While there have been reports of successes in many low-resource countries on the benefit of POCUS, many others have not implemented this strategy. It is known that the universal adoption of certain strategies is influenced by different factors, including culture, religion, staff, policies, among others. There was paucity of data on POCUS in Nigeria and Africa at large as at the time of this review. Very few studies have demonstrated POCUS in a unit but this study targets to scale up across the various PHC facilities in the state. The Edo state health service has had no experience with POCUS despite its investment in various areas of primary healthcare. Following further investment, through a grant that provided mobile ultrasound machines, the opportunity arose to implement task shifting POCUS. This study aims to document the feasibility of POCUS in the PHCs through task-shifting, the initial experience with this introduction by assessing the lived views of the trained providers of this service following its deployment. This is aimed at providing needed feedback to help modify utilization of the service, improve service delivery, and inform policy development.
2. Materials and Methods
This was an exploratory qualitative study conducted four months after basic Obstetric scan training, aimed at an initial review following the implementation of an Obstetric POCUS training program for medical officers, nurses, and midwives. The study also employed aspects of implementation research design to review implementation and assess the experiences of the trainees after commencement of POCUS services in the PHCs.
The Edo state government, in collaboration with the Fetal Diagnostic and Ultrasound Centre (FDUC), with support from the World Bank Impact-plus project, provided one portable battery-operated ultrasound machine per Local Government Area (LGA) as well as trained two (2) primary health care providers (medical officers, nurses, and midwives) per LGA to provide basic Obstetric POCUS to clients. Of the 18 LGAs in Edo State, two primary health care workers involved in offering antenatal services were selected to cover every area of the state. The training was conducted over three (3) weeks, first with a 2-week virtual theoretical training held thrice weekly, each session lasting two hours. This was followed by a 3-day intensive hands-on training (9 am - 5 pm daily, with 2 break sessions of 30 minutes each) at Oluku PHC, Edo State, in February 2025. Four months following training and deployment of scans, this survey was conducted at various PHCs where implementation of obstetric POCUS services had commenced, to document the on-site experience of the provision of this new service. Purposive convenience sampling was done across the three (3) senatorial districts to obtain a total of eighteen (18) out of the 36 health care workers trained; one (1) per LGA. A mentoring/supervision program was established afterwards to follow up with trainees and supervise the work done. There is also a plan for a refresher course annually to ensure continuity and quality control.
Figure 1. Portable battery-operated scan machine deployed for POCUS at Edo PHCs; back view.
Figure 2. Portable battery-operated scan machine deployed for POCUS at Edo PHCs; inside view.
2.1. The Training Curriculum
The curriculum, which had been developed by FDUC - an ultrasound training institution that had offered practical ultrasound training in West Africa for over a decade and was endorsed by the International Society for Ultrasound in Obstetrics and Gynecology (ISUOG), was deployed for this training. Key competencies targeted were: understanding the working of the ultrasound machine, appreciating the anatomy of the adnexae, uterus, and its content on ultrasound, obtaining accurate images while scanning, placental location, fetal biometry and weight estimation, as well as pregnancy dating/gestational age assessment, and maintenance of the ultrasound machine.
2.2. The Training
The onsite training took place at Oluku Primary Health Care Centre, Benin City, Edo State, in February 2025. The targeted participants were medical officers, nurses, and midwives. These were the health workers that offer antenatal services to women at the PHCs. A total of 36 health workers were trained, two (2) per primary health care facility in each of the 18 LGAs in the state. The training involved demonstrations with both mannequins and consenting live pregnant women. The trainees had pre- and post-test assessments, trainee checklist assessment, and were also tasked with demonstrating the competencies gained from the training in a live demonstration session with participants from each group. They were able to perform instructed tasks on basic Obstetric scanning. Despite most of the participants being ultrasound-naïve, the training proved to be impactful as they were able to successfully scan their volunteers, making accurate obstetric diagnoses while carrying out their task. At the end of the training, the participants were given Ultrasound machines for their various PHC centers to commence Obstetric POCUS immediately.
Figure 3. Participant performing live scans during training.
Figure 4. Participants performing live scans under the trainers’ supervision.
2.3. Qualitative Interviews Following the Training
Four months following training and implementation of POCUS services in the PHCs, eighteen (18) interviews were conducted with the trainees to explore their experience of the training and provision of POCUS services. Responses from the interviews were audio-recorded, transcribed, and a thematic analysis was conducted. The questions asked during the interviews were about the experiences of the trainees about the obstetric ultrasound training, the skills gained, how the skills gained had improved clinical work and well-being of clients, as well as challenges experienced while providing ultrasound services. The interviews were conducted by trained research assistants till data saturation was attained, audio-recorded, and later transcribed. The transcripts were reviewed against the audio-recordings to ensure that the right message had been obtained. Thematic analysis was inductive in nature, where the transcribed data was read several times to identify patterns of meaning called codes. The codes were again related to each other to form categories, and the eventual themes that were used to report the findings.
3. Results
3.1. Socio-demographic Characteristics
Table 1. Socio-demographic Characteristics of participants.
Variable | Frequency (n=18) | Percent |
Age (in years) | | |
21-30 | 2 | 11.1 |
31-40 | 10 | 55.5 |
41-50 | 4 | 22.3 |
51-60 | 2 | 11.1 |
Mean Age ± SD = 38.8 ± 8.2 |
Total | 18 | |
Gender | | |
Male | 16 | 88.9 |
Female | 2 | 11.1 |
Total | 18 | |
Profession | | |
Doctor | 16 | 88.9 |
Nurse/Midwife | 2 | 11.1 |
Duration of clinical practice (in years) |
<10 | 11 | 61.1 |
10-20 | 5 | 27.8 |
>20 | 2 | 11.1 |
Majority of the trainees were within 31 to 40 years age group and less than 10 years work experience. Two of the participants had prior ultrasound training but had never utilized the skills. Seventeen PHCs had commenced POCUS services in their LGAs, while one was yet to commence due to ongoing infrastructural renovations in the facility. A total of 622 scans had been done over the 4-month period in 17LGAs, averaging 8-11 scans per LGA every month.
3.2. Qualitative Interviews
Four (4) themes were generated, including: (1) Obstetric ultrasound skills gained; (2) Improved patronage and management of pregnant women; (3) Clients’ satisfaction, and (4) Challenges.
Theme 1: Training experience and Obstetric Ultrasound skills gained
The participants demonstrated satisfaction with the training experience and competence in the obstetric ultrasound skills they had gained, which involved dating pregnancies, identifying abnormalities, and identifying key obstetric indicators of either good or poor outcome. The skills gained seemed to be valuable in daily clinical practice.
“During the training, I was able to acquire the skills to accurately get the gestational age, the expected date of delivery, abnormal presentation, placenta location, and all of that, which are actually the basic skills required for the point of care, and they’ve actually been of great help since then.”
“We learned a great deal about determining the presentation and lie of the fetus, locating the fetus, assessing fetal viability, and identifying abnormalities that require emergency care.”
“I’m able to do fetal biometrics. I’m talking about the bi-parietal diameter (BPD), the femoral length, the head and abdominal circumferences, which will help you to determine the gestational age.”
“Because a lot of women in our society are not really sure of their last menstrual period, the estimation of gestational age we learnt goes a long way in helping with that.”
“I will describe the training as a mixed bag because it was a combination of learning new methods of scanning and re-awakening of my long-forgotten skills. It was a good one.”
“Before the training, I had very little experience with scanning. This training allowed me to learn significantly and perfect my scanning skills.”
From the responses, one can deduce that the training was impactful and helped the trainees acquire valuable skills for routine clinical practice.
Theme 2: Improved management of pregnant women
An important aspect that came up was the benefits of the skills gained, as it concerned the quality of care provided to clients. Most of the responses provided insight into patient experiences as improved, and the health care providers are further empowered to deliver timely interventions and referrals where necessary.
“I can give examples off the top of my head. I think the first scan I did was even for a placenta previa. The placenta is beneath the head of the baby. The woman came in bleeding, and before, we would have asked for her previous scan reports. Instead, I just told them to bring the scan machine. I viewed and saw that the placenta was very low lying. We immediately took it up from there. We counselled her for a Cesarean section.”
“The scan machine helps us identify cases with potential delivery challenges as high-risk for timely referral. I encourage mothers to undergo scans at our health facility to provide them with updated information about their pregnancy.”
“Scanning has actually made us more certain about the nature of our clients’ pregnancies. It has made us more certain of the interventions we may need to provide for them through the course of antenatal care and the delivery.”
“Most of the time, we've been able to save two lives, because of what we saw from scanning; saved the mother, saved the baby, and also saved the husband from being a widower.”
“There are some of our clients who come at the point of delivery. You do not have any history with them. They didn't come to any antenatal clinic, but they are presenting to you at the point of delivery. So, the ultrasound scan is a quick point of care screening for us to quickly know the presentation of the baby.”
“When we started, we did health education and advocacy, you know, telling the people, creating awareness, sensitizing them that scanning is being done here. So, even other facilities that are in the LGA send patients from their own facilities for a scan. So, it has really greatly improved the number of patients we have been seeing.”
“Oh! There's no more time wasted on diagnosing complex cases. We can just use the ultrasound scan to diagnose what we need to.”
“We have been able to make some timely interventions, especially during the third trimester. We have spotted several cases of polyhydramnios, oligohydramnios, breech presentation, and even transverse lie for several women.”
“The mothers are happy about it because they can get firsthand and direct information on the welfare and well-being of the fetus before delivery. Before the service was introduced, they went to other facilities for ultrasound, which eventually made them pay much more.”
“…mothers know that emergency scans can be performed when needed in the PHCs…”
“When we started, we did health education and advocacy, you know, telling the people, creating awareness, sensitizing them that scanning is being done here. So, even other facilities that are in the LGA send patients from their own facilities for a scan. So, it has really greatly improved the number of patients we have been seeing.”
From the responses above, one is able to infer that when these health care providers use the POCUS device to make assessments of pregnant women presenting to the clinics, it not only improves management, but also improves ease of diagnoses, reduces morbidity, and possibly mortalities.
Theme 3: Providers’ perception of Clients’ experiences
The healthcare providers reported that clients have demonstrated satisfaction and elation since the provision of scanning services in the PHCs. It was noted from the responses that the introduction of scan machines has increased clients’ patronage and ante-natal registration, reflecting a renewed confidence in utilizing the PHCs. Remarkably, the pregnant women are saved the long distances they had to travel to get ultrasound services, especially during emergencies.
“When we announced it to the patients, it was like a celebration.”
“It's been very exciting having an ultrasound machine at the health center. The mothers are happy about it because they can get firsthand and direct information on the welfare and well-being of the fetus before delivery.”
“Before the service was introduced, they went to other facilities for ultrasound, which eventually made them pay much more.”
“It has improved our antenatal patronage; patients have been coming because of the scan, because it is cheap. A lot of patients are coming, more have registered for antenatal compared to before, and when they are coming next time, some of them even bring their friends over for us to scan.”
“Our delivery rates have increased significantly. This is evident because most women are now happy to register at our facility, knowing that emergency scans can be performed when needed.”
Theme 4: Challenges
While reporting positive experiences, the participant had challenges with the implementation of POCUS in the PHCs in the following areas;
Power/Equipment-related: The absence of a continuous power supply was reported; outages were so frequent that the charged batteries got drained while patients were still waiting to be scanned, especially in facilities yet to receive solar panels as an alternative power source. The need for accessory devices was also pointed out. The provision of printers suitable for the scan devices was also pointed out, as clients were interested in printed copies of their reports rather than hand-filled ones, as other commercial ultrasound centers do.
“We have power issues. At times, it can be a problem for us. We need solar panels for when the batteries get drained and there are still patients to scan. “
“There is the issue of materials, or disposables that are needed for the ultrasound services, such as the gel and other materials. The costs of them in the market keep increasing, so we struggle to ensure that we don't have to start reviewing the cost of the ultrasound services. “
“…and most times, they request printed copies of the images after scanning...”
Human Resources: The need for more persons to be trained to fully address the human resource gap in the LGAs was also pointed out.
Further training was suggested to enhance the skills of service providers. The provision of printers suitable for the scan devices was also pointed out, as clients were interested in printed copies of their reports rather than hand-filled ones, as other commercial ultrasound centers do.
“I think we still need even more skills, more training to enhance our skills.”
“I find it challenging to identify the sex of the baby while scanning, I'm still yet to fully get it.”
“It's the problem of staffing. For example, during my antenatal clinic, I have to see over 40 to 45 patients. From these, about 8 to 9, will actually require scanning. So, only I running antenatal and carrying out scanning has actually been A challenge. So, if we can actually tackle this issue of staffing, it will go a long way to help us.”
“If another training opportunity arises, it should include other healthcare personnel in the LGA.”
“So, most people are really interested in knowing the sex and knowing the well-being of the fetus. So that's the challenge. And most times they need printed copies of the images.”
4. Discussion
This study revealed that almost all the centers had started obstetric POCUS services at the primary health care level in Edo State, following training on basic obstetric ultrasound scanning, and the deployment of portable rechargeable scan machines. It also highlighted major challenges such as epileptic power supply despite having battery-powered ultrasound systems, increased workload, and the need for follow-up training and measures for quality assessment.
Adoption of POCUS at the Primary Health care level: The introduction and adoption of POCUS in maternal and child care at Edo State primary health centers was driven by the need to provide quality and affordable sexual and reproductive health care services, as outlined by SDG-3
, to reduce maternal and perinatal morbidity and mortality. The training was part of an intervention to improve health care services for mothers and children at the grassroots level in Edo State, Nigeria. Given the shortage of skilled health workers, especially specialists, adopting task shifting becomes essential. The initial challenge was the feasibility of training PHC health workers on basic scanning to enable patient access to point-of-care ultrasound. Initially, it looked unachievable, but through the Edo State Government, FDUC, and support from the World Bank through the IMPACT-plus project, whose development objective is to reduce maternal and under-5 morbidity and mortality in Nigeria by improving access to quality services at the PHCs. This became a reality in low-resource settings and is currently ongoing. This is in keeping with study of empowerment on obstetric scan in a 5 days training program
| [23] | Enabudoso E, Awowole I, Thompson O, Okoror C. Despite the Long Learning Curve for Ultrasound, How Beneficial Is A 5-Day Basic Obstetric Ultrasound Training for Foetal Biometry. AJFMED. 2024 Jul 21; 3(1): 20-5. https://ajfmed.com/index.php/ajfm/article/view/68 |
[23]
. This is the first reported in Nigeria and West Africa to successfully empower PHC workers with basic Obstetric scan skills for POCUS on such a large scale.
Feasibility, acceptance and implementation of POCUS in Edo state: the study confirms feasibility of POCUS using task shifting of training PHC health workers to fill the gap for shortage of sonologist in Edo state. Trainees include medical officers, nurses and mid-wives as seen in study done at Ethiopia where nurses and midwives were trained but only involved a unit
| [19] | Dalmacion GV, Reyles RT, Habana AE, et al. Handheld ultrasound to avert maternal and neonatal deaths in 2 regions of the Philippines: an iBuntis_ intervention study. BMC Pregnancy Childbirth. 2018; 18(1): 32. https://doi.org/10.1186/s12884-018-1658-8 |
[19]
unlike in Edo state which cuts across all the PHCs in the state. It has been implemented in almost all the PHC facilities in the state. There is a general acceptance both by the patients and the trainees. The funding of this program was a major factor to its feasibility.
Statewide Integration of Training and deployment of POCUS: From the findings, 94% [Seventeen (17) out of the Eighteen (18)] of the Local Government PHC facilities trained had commenced and implemented POCUS in their antenatal care services; the one yet to commence is due to ongoing renovation in the health facility. The commencement of POCUS occurred between one- and four-weeks post-training. This was feasible because scanning machines were deployed to PHC facilities immediately after training, along with the enthusiasm of the trainees. The training was beneficial, and participants reported positive experiences centered around the importance of gaining skills in obstetric ultrasound and improving the management of pregnant women. This is similar to what was reported in a Sub-Saharan Country, where task shifting was done to improve the antenatal experiences of mothers through ultrasound services
| [18] | Aloysius G. M, Geoffrey E., Nassanga R. and Kiguli-Malwadde E. Point of care obstetric ultrasound training for midwives and nurses: implementation and experiences of trainees at a rural based hospital in Sub-saharan Africa: a qualitative study. BMC Research Notes (2023) 16: 287 https://doi.org/10.1186/s13104-023-06569-8 |
[18]
. While this was done in a single PHC facility in Uganda, Edo state was able to replicate the experience across Eighteen (18) PHCs in each of the 18 local government areas in the state.
Rich Qualitative Insights into Achievements and Barriers: The primary health care system is the initial primary contact of many mothers who report for antenatal care, and the health workers indeed perform the initial maternal assessments and examinations from which they make their clinical judgments on whether to refer the mother or not, to a Secondary or Tertiary care facility. The findings from this study reveal that POCUS has the potential to improve the clinical assessments and decision-making efforts of healthcare providers, aiding efficient management of pregnant women. This is in tandem with the findings of an Ethiopian study.
| [20] | Abawollo HS, Tsegaye ZT, Desta BF, Beshir IA, Mengesha BT, Guteta AA, et al. Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study. BMC Pregnancy Childbirth. (2022) 22(1): 368. https://doi.org/10.1186/s12884-022-04703-1 |
[20]
As a point-of-care assessment tool, ultrasound can provide an optimum tool for health care providers to make quick check-ups and assessments of pregnant women before deciding on the appropriate line of care. The findings from this study reveal that the intervention has begun to nullify the need for mothers to travel long distances for scanning before or after their antenatal visits and also quickly identify high-risk cases that require immediate clinical intervention, improving maternal outcomes during pregnancy and delivery. This is supported by a study from the Philippines, which showed that 6.3% of maternal deaths and 14.6% of neonatal deaths were averted by introducing task shifting for POCUS services by Community health extension workers.
| [19] | Dalmacion GV, Reyles RT, Habana AE, et al. Handheld ultrasound to avert maternal and neonatal deaths in 2 regions of the Philippines: an iBuntis_ intervention study. BMC Pregnancy Childbirth. 2018; 18(1): 32. https://doi.org/10.1186/s12884-018-1658-8 |
[19]
The realities of implementing POCUS for obstetric care in PHCs, as revealed by the study, also highlight that erratic power supply is a major hindrance to continuous service provision. This is especially marked for centers yet to benefit from the ongoing provision of solar energy as an alternative power source in the PHCs. Studies in rural Uganda and Ethiopia reported similar challenges.
| [24] | Shah S, Santos N, Kisa R, et al. Efficacy of an ultrasound training program for nurse midwives to assess high-risk conditions at labor triage in rural Uganda. PLoS One. 2020; 15(6): e0235269. https://doi.org/10.1371/journal.pone.0235269 |
| [18] | Aloysius G. M, Geoffrey E., Nassanga R. and Kiguli-Malwadde E. Point of care obstetric ultrasound training for midwives and nurses: implementation and experiences of trainees at a rural based hospital in Sub-saharan Africa: a qualitative study. BMC Research Notes (2023) 16: 287 https://doi.org/10.1186/s13104-023-06569-8 |
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The presence of alternate power sources like solar energy or even a power-generating set, to help charge batteries, will enhance the continuous utilization of the scan machines and prevent the need to turn clients away or book their scan appointments for other days.
Overall, this study has demonstrated that the implementation of POCUS services for obstetrics in PHCs with task-shifting to address the specialist gap facilitates improved care and management of pregnant women. Mentorship, monitoring of the intervention and re-training are the way forward to ensure sustainability.
Strength of the Study
1) Novel implementation of POCUS in PHC facilities in Nigeria.
2) State-wide coverage across all 18 local government areas.
3) Integration of training, financing, deployment, and evaluation.
4) Rich qualitative insights into achievements and barriers.
5) Practical implication for scale-up in LMICs; it has provided very useful themes that will be invaluable in designing a larger-scale evaluation of this program. This report represents our first documentation of this ongoing program and forms the basis for further evaluation.
Limitations
1) The study was qualitative in nature and had a small sample size, hence, limited generalizability.
2) Short post-training follow-up period; the interval for the post-training follow-up is quite short and may not be a good predictor of sustainability.
3) The possibility of bias cannot be ruled out, as workers in an establishment may sometimes not want to discredit their employers. Attempts were made to mitigate these by de-identifying the responses and assurances that this survey was aimed primarily at auditing the present task to improve the service.
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