Some notes on my first experiences with obstetric sonography in Tanzania, the role of point-of-care ultrasound in improving prenatal health in its rural areas, and how Midwife Without Borders hopes to further contribute to the use of prenatal sonography in Northern Tanzania in the near future.
I gained my first experience with prenatal sonography in Africa earlier this year, when I was a medical volunteer at FAME, a hospital in the middle of Masaai land in Northern Tanzania. At FAME, they have one mobile Sonosite ultrasound system available for the whole hospital. It was probably one of the hospital’s most used medical devices. On several occasions, I had to search all departments to locate it and then patiently wait for my turn to use it.
This ultrasound machine served (and still serves) a wide range of purposes and some of the local doctors are very skilled in using it, even to the point of inventing new diagnostic methods. In particular, the use of abdominal and obstetric sonography proved its life-saving potential time after time. To name just a few, it allows for the detection of internal bleedings after abdominal trauma, the tracing of severe cases of (erupted) ectopic pregnancies, and the discovery of cases of intestinal obstructions, liver abnormalities and tumors.
At FAME, pregnant women are offered a prenatal program that involves regular ultrasound check-ups. One of my first prenatal scans turned out to be a bit of bad luck. A Masaai woman presented herself mid-pregnancy. Before starting the scan, I asked the husband to stand behind me so that he could follow the examination on the screen. However, as soon as I put my probe down I realised that what I was seeing was not good: a foetus in an advanced stage of demise, a total hydrops with clear malformations, and no heartbeat. Unfortunately, we could not convince the woman to be admitted to the ward for expulsion. She persisted that she could “still feel the baby walking in her stomach” and there was no way we could persuade her that she was probably feeling bowel movements and that her life was at risk. She persisted in wanting to go home. It really is heartbreaking to see the feet of a mother going down the road to a probable death while we had everything at hand to save her life. This case further convinced me of the fact that performing a scan in itself is not necessarily always life-saving; it also showed me yet again that people’s right to not being treated, can only be used well when a truly informed decision can be made. That is, when the patient has a good understanding of his or her situation. It follows that introducing prenatal sonography should always go hand in hand with prenatal or even preconceptional education.
While doing prenatal scans at FAME, I saw several cases of low positioned placenta, one of placenta praevia and one of a funic (cord) presentation. Thanks to the early detection we could follow up those cases, schedule an extra check up in the third trimester or plan a primary c-section. If those cases would have remained undetected and thus unattended, the situation might have become life threatening for mother and/or baby. I also detected one twin pregnancy, several missed abortions, a couple of cases of oligohydramnios and some cases of severe polyhydramnios. The timely detection allowed us to design the right, tailor made care plan for these patients and thus reduce the risk of unfavourable pregnancy outcomes.
In the labour ward, I regularly used sonography to confirm fetal positioning and presentation and placenta localisation, especially when labour was not progressing well or when there was a higher than average blood loss. Postnatally, sonography was put to good use to check for intrauterine placenta remains in case of excessive bleeding and subinvolution of the uterus. In quite a number of cases, routine prenatal ultrasound check ups gave me a strong feeling that we were dealing with intrauterine growth retardation. However, due to the lack of a proper and systematic early dating of pregnancies and the absence of a good charting system, it was next to impossible to say anything clinically profound about the fetal growth evolution, especially in cases of a symmetric growth retardation.
This brings me to what I consider to be the major challenge of using fetal biometrics in a rural setting. It only makes sense to do biometrics when you also have a protocol for dating pregnancies and for charting growth. Besides, you need to train sonographers to measure according to international set standards. I sometimes noticed that the due date was continuously adjusted during a pregnancy. However, with a proper benchmark lacking, it becomes impossible to make valid claims about fetal growth and to detect cases of growth restriction or macrosomia. I saw first-hand that using prenatal ultrasound in the wrong way can at some point (and unintentionally) do more harm than good. If, for instance, there is no medical indication but you still perform an elective c-section because of an incorrect due date based on an ultrasound scan, it should not come as a surprise that you end up with a premature baby with unnecessary complications.
Let me list a few of the challenges I came across when using sonography in a resource poor setting. You can imagine when the different challenges boil together in the same case, it can easily turn sonography into a concept of disaster instead of into an instruments of added value.
Equipment: the ultrasound equipment is often of basic and rather poor quality, proper visualisation is often a challenge and does not always allow for high precision measurements. The margin of error in measurements is definitely higher than when using a high definition sonography device.
Sonographer: not everyone is performing the scan according to the same standards of measuring. Furthermore, not everyone has had enough training to make even basic anatomical distinctions, which will highly compromise the biometrics and the general observations.
Estimated due date: women often don’t know the first day of their last menstruation and come for their first prenatal control in the second semester instead of the first. In these cases, the estimated due date can not be defined based on the crown-rump length and often there is no protocol for proper dating in late pregnancy. The possible outcome is that the due date is set rather arbitrarily or that it is based on the estimation of the due date according to the last biometrical measurement.
Documentation: it matters which grow charts are used and how they are used. Besides, the documentation of the results should be charted and subsequent scans should be plotted in the same charts.
After returning from Tanzania, I got in touch with and became a volunteer for the Dutch NGO Mount Meru. This NGO is active in Northern-Tanzania to support the local health care system in its efforts to reduce the high maternal and neonatal mortality rates. Mount Meru’s core business is to provide point-of-care ultrasound equipment and sonography training in rural areas in Tanzania. My first experiences in Tanzania with performing ultrasounds and training others in doing so, taught me that the combination of equipment and training is key to assuring maximal positive effect. I am really looking forward to keeping cooperating with local health care professionals to improve mother and child care in the region. More on that in my next blog, so stay tuned!
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