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A Challenging Chance - Introducing Obstetric Sonography in Rural Tanzania

At Midwife Without Borders, we witnessed first hand how obstetric sonography can be a real lifesaver in rural areas in Tanzania, so making it available in more places is the logical thing to do. That does come with some challenges though. The third part of a short series on antenatal care in Tanzania.

Over the last years, the Tanzanian government has been putting a lot of effort into reducing the nations’ high maternal and neonatal mortality and morbidity numbers by increasing reproductive, maternal, newborn and child health (RMNCH) services.

RMNCH services can benefit from introducing obstetric sonography, as ultrasound is an important aspect of quality antenatal care services. In their 2016 Recommendations on Antenatal Care, the WHO recommends that all pregnant women get at least one ultrasound scan before 24 weeks of gestation (early ultrasound) to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce induction of labour for post-term pregnancy, and improve women’s pregnancy experiences.

An ultrasound scan performed by a skilled sonographer allows for accurate pregnancy dating, detection of potential life-threatening complications (such as fetal malpresentation, multiple gestations, ectopic pregnancy, placenta praevia, fetal anomalies, and growth retardation) and timely referral and management. Furthermore, obstetric sonography is a relatively low-cost and non-invasive intervention. All in all, it is likely to contribute to further improving maternal health and reducing child mortality (Sustainable Development Goal 3).

Currently however, coverage of obstetric sonography in Tanzania is low, especially in rural areas. This is highly unfortunate, since in these areas in particular it can be a lifesaving diagnostic tool. Further introducing obstetric sonography would be highly beneficial, but it does come with some challenges on several levels though, which can only be overcome by uniting forces.

​​Accessing care can be difficult

​​Pregnant women in rural areas often delay their decision to seek care, due to duties at home, lack of permission of their husband, fear of financial implications, a poor understanding of signs of pregnancy related complications or previous negative experiences with the health care system. When they do seek care, they might be confronted with challenges in getting to the right place, such as costs of transportation, road quality, rain season, long travel distance to the dispensary or health center et cetera. When they do actually get to the right place, they might face delay in receiving adequate care due to lack of diagnostic instruments (such as ultrasound equipment) or sufficiently trained staff able to recognize high risk situations. Another delay in reaching care can result from hiccups in the referral system: in some cases, by the time women have reached a specialised center, it may already be too late to properly manage the complications.

To improve the diagnostic capacity in remote areas and enhance accessibility, the WHO states that “it may be feasible to task shift antenatal ultrasound to midwives with the appropriate training, staffing, mentoring and referral system in place”. Thus, the accessibility of obstetric sonography in Tanzania can be increased by:

  • increasing the availability of mobile point of care ultrasound in health centers and dispensaries

  • training midwives in rural areas to perform quality scans

  • providing adequate supervision at a distance through mHealth applications to guarantee the quality of scans

  • setting up a referral system with a clear care path: which ultrasound findings require a referral and in what time path and to which specialist center?

  • boosting the obstetric ultrasound expertise in referral hospitals

  • lowering the financial threshold to receive an antenatal scan in rural areas by offering two free scans during pregnancy (one of which should be an early scan)

​​​​Infrastructural & logistical challenges

​​​​​In most of Tanzania’s rural areas, the minimum target of 1 ultrasound machine in 50,000 people is not reached. A wide range of infrastructural and logistical problems contributes to this:

  • a lack of quality ultrasound equipment

  • poorly maintained equipment lacking the necessary updates

  • equipment that does not function due to a lack of spare parts

  • brand new sponsored equipment remains unused due to a lack in trained staff or a reliable power supply

  • patients or hospitals lack the budget to cover costs (for staffing, ultrasound gel, maintenance, power et cetera)

Possible solutions are:

  • making an inventory per region of available sonography equipment in health care institutions, as well as its technical capacity, age and state, expected life span et cetera

  • training staff in performing obstetric sonography and providing ongoing training

  • making prenatal obstetric scans part of the government’s prenatal program

  • setting up a network of clinical application specialists who can keep the ultrasound machines running and up to date

  • including maintenance, supplies (ultrasound gel, batteries, updates et cetera), technical support and staffing costs into the health institution’s logistical budget

Training challenges

​​The usefulness and quality of an obstetric ultrasound scan is largely defined by the professional quality of the caregivers making the scan. In the hands of an untrained practitioner, ultrasound can lead to a wrong diagnosis and can result in serious negative consequences for mother and child. The same applies when a practitioner lives and dies by ultrasound findings instead of combining them with clinical observations and other findings. One example of what can easily go wrong, is holding the probe in the wrong direction. This might lead an untrained practitioner to conclude that the child is in a breech position, while in reality it has a cephalic presentation, which can eventually lead to the decision to perform an unnecessary cesarean section. Another example is performing fetal biometric measurements in the wrong scan planes, which can result in over- or underestimating growth and might lead to the wrong clinical decisions (such as inducing of labour for babies who turn out to be premature).

Caregivers’ theoretical and in particular their practical training are thus key here. In Northern Tanzania, the referral hospital Kilimanjaro Christian Medical Centre (KCMC) is putting great effort into training medical professionals by offering a three months short course in diagnostic ultrasound. This course includes obstetric as well as abdominal and gynecological sonography. However, since ultrasound in the field of obstetrics and gynaecology is getting more and more specialised and is gaining importance in public and private practises in Tanzania, there is a need for specialised programs for training OB-GYN sonographers.

This can be done by:

  • training a body of OB-GYN sonography professionals who can serve as mentors and supervisors and who will also train other sonographers to reach an advanced level of OB-GYN sonography

  • strengthening existing courses with a specialization in OB-GYN sonography and provide local training programs to improve and maintain expertise

  • collaborating with leading international organisations such as ISUOG, the International Society of Ultrasound in Obstetrics and Gynecology, and having experts visiting regularly to boost education programs

  • striving to work according to internationally agreed standards and nationwide agreed protocols

  • deciding which nomogram for fetal biometrics would best suit the Tanzanian population

Educational challenges

Currently, both the population in rural areas and health care providers have little knowledge of the possibilities and limits of obstetric sonography. Unrealistic fears and unrealistic expectations can influence care-seeking behaviour, acceptance of ultrasound and service uptake. Authorities and health care providers can play an active role in making the population more familiar with the procedure, purpose, benefits and limitations of obstetric ultrasound.

They can do this by:

  • making obstetric sonography an obligatory part of the education of health care professionals so that they can properly inform parents

  • providing educational information through media channels, for ads on national television, posters et cetera

  • integrating information on obstetric sonography in Reproductive and Child Health programs for future parents

  • integrating information on obstetric sonography in health education classes in the final years of high school

​​Regulatory challenges

Under current regulations, a medical professional in Tanzania (for instance a midwife) can obtain the sonographer assistant license from the Medical Radiology and Imaging Professionals Council (MRIPC), that keeps a list of qualified sonographers. However, it does happen that unqualified and poorly trained sonographers offer sonography services anyway. In order to improve the quality of the services, to reduce the abuse and misuse of ultrasound services and to obviate the practise of untrained and unqualified OB-GYN sonographers, it is paramount to set up a system of supervision and control of OB-GYN sonography practices.

The Tanzanian authorities can play an active role in the appropriate introduction of OB-GYN sonography in (rural) Tanzania by strengthen the requirements meant to safeguard the quality of obstetric sonography, it might be beneficial to:

  • strengthen supervision on OB-GYN sonography services provided by (private) institutions

  • have all facilities providing ultrasound services and their equipment registered by the regulatory authorities

  • let the quality of the available equipment and staff be the decisive factor in determining the range of ultrasound services a health care facility is allowed to offer

  • issue clear guidelines (where these are not yet available) on who is allowed to provide sonography services, what the mandatory level of training is and which training institutions are qualified to hand out the certifications needed to obtain a license

  • formulate continuous training requirements for those who have obtained a license

Creating Chances

Together with its local partners, the Dutch Mount Meru Foundation focuses on training midwives and supervisors in obstetric sonography for the rural areas of Tanzania. United with our Tanzanian fellow health professionals, we strive to make a real and positive impact on the clinical management of pregnancy complications and improve the outcome for both mothers and babies. If you want to know more about what we do, click here. If you’re interested in supporting our projects, click here.

Read the first and second part of this series here and here.

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