Addressing Obstetrical Challenges at 12 Rural Ugandan Health Facilities: Findings from an International Ultrasound and Skills Development Training for Midwives in Uganda

Introduction

Uganda, like much of Sub-Saharan Africa, is facing critical maternal and fetal health challenges. According to the 2011 Uganda Health Assessment, the Ugandan infant mortality rate is 76 infant deaths per 1,000 live births, which is over 10 times the infant mortality rate as the United States.[1,2] According to the 2012-13 State of Uganda Children Report, Uganda’s maternal mortality ratio is 438 per 100,000 live births, which is one of the highest rates in the world.[3]

The lack of antenatal care (ANC) is a contributing factor to Uganda’s maternal and fetal health challenges. It is estimated that 6% of Ugandan women receive no antenatal care and the majority (68%) of women receive less than the World Health Organization (WHO) recommended four antenatal care visits.[1] In fact, the minority (39%) of Ugandan women deliver at health facilities.[1] While the problem is severe in the country of Uganda as a whole, it is even worse in rural areas because of additional barriers faced in rural areas including the cost and reliability of transportation,[4,5] inadequate nutritional education,[6] long wait times caused by high patient volumes,[5] and lack of imaging capabilities in rural areas.[7]

According to the 2011 Ugandan Health Assessment, 84% of women receive their antenatal care from midwives.[1] Since midwives comprise the majority of the antenatal care providers, there is compelling reason to seek their perspectives in facing Uganda’s critical maternal and fetal health challenges. Despite the rich first-hand knowledge of the field conditions of the rural Ugandan midwives, the rural Ugandan midwives perspectives are not represented in the literature. The purpose of this paper was five-fold: 1) to assess the perspectives of rural Ugandan clinics on current barriers to antenatal care (ANC); 2) identify deficiencies in prenatal services and anticipated new demands with the addition of ultrasound; 3) to assess rural Ugandan midwives’ perspectives on the perceived challenges they would face by adding ultrasound to their health facilities and identifying knowledge deficiencies in the management of prenatal conditions primarily diagnosed with ultrasound; and 4) to conduct a cost analysis for ultrasound training and equipping of midwives at rural Ugandan health facilities.

Methods

Subjects

This study included a prospective survey of 12 midwives at 12 rural Ugandan health facilities that provide antenatal care at 11 districts in Uganda including Kanungu, Kampala, Manafwa, Wakiso, Rukungiri, Lira, Bugiri, Arua, Kisoro, Kabale, and Nebbi (Figure 1). Two of the facilities were level IV and the remaining 10 facilities were level III facilities. According to the Ugandan Health Sector Strategic Plan,[8] a Health Center IV is the county-level health facility that employs a physician and is equipped with an operating theatre and blood transfusion services. A Health Center III is a sub-county level health facility, which is run by mid-level providers and offers basic maternity services and diagnostic services.

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Figure 1

Location of 12 clinics where ultrasound machines were donated and midwives were recruited and trained

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Results

All 12 midwives completed the survey on the first day of their ultrasound training course. The 12 midwives completed their clinical training at 10 different programs across Uganda. All 12 midwives see patients for antenatal appointments. All the midwives reported that all HIV positive pregnant women received anti-retrovirals (ARVs) provided free of charge to the patients. None of the midwives had ever received obstetrical ultrasound training as part of their curriculum. Further questionnaire results are reported in Table 1. The second portion of the survey included a knowledge assessment of the diagnosis and comfort level in managing 11 prenatal diagnoses primarily made with ultrasound as shown in Figure 2.

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Figure 2

Midwives’ Self-Assessment. Response averages of 12 midwives using rating scale of 1 to 3.

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Discussion

The 12 midwives at the rural Ugandan health facilities in this study reported managing over 6,700 ANC visits and performing over 2,100 deliveries annually. Their referral rate to a physician was only 3.2%. This underscores the fact that the midwives are primarily managing their patients[1] and emphasizes the importance of gaining their in-the-field perspectives on obstetrical challenges in rural Uganda.

The rural midwives’ self assessment of clinical management skills demonstrated scores ranging between “not at all comfortable” to “somewhat comfortable” in 9 of 11 (81.8%) selected diagnoses despite their mean 2.5 years of education and an additional 2.5 years of experience in the field. This is attributable to the lack of ultrasound training in their practices. Ultrasound is generally required to diagnoze all 11 conditions surveyed and has many other uses, including dating the pregnancy, second trimester fetal screening, and in labor and delivery, to predict whether vaginal delivery will be successful.[10-12] The utility of ultrasound is key in timely diagnosis, which allows for labor management preparation, delivery route planning, and early appropriate referral of certain conditions, especially those that might otherwise be fatal. According to the data, fetal macrosomia was one of the least understood diagnoses among the midwives in the study. However, according to recent literature, diabetes and obesity in women of reproductive age is increasing in developing countries, including Uganda, leading to a rise in macrosomic births and adverse birth outcomes.[13] Antenatal ultrasound diagnosis of macrosomia and attendance at delivery by a midwife who is prepared for potential shoulder dystocia could dramatically decrease the morbidity and mortality of such deliveries.

With respect to the critical issue of antenatal care attendance rates, 7 out of 12 (58%) of the midwives reported that women typically attended less than the recommended four ANC visits, which is similar to published ANC rates in the literature[1] and highlights the fact that low ANC attendance is still a problem in rural areas. In addition to the major barrier to ANC attendance of lack of transportation,[4, 5] lack of ultrasound is also a barrier to women seeking ANC services. This has been substantiated in prior studies which suggested that technology increases trust in the care provided and husbands were even more likely to accompany their wives to visits in order to see the scan.[13,14] The midwives reported caring for an average of 9.8 HIV positive patients per month and the increase in ANC attendance that might result with the addition of ultrasound technology, may potentially help ensure appropriate treatment to decrease maternal child HIV transmission.

Additionally, it has been shown that ultrasound implementation at antenatal visits increases the referral rate to obstetricians who can provide care for higher risk pregnancies, in one study, as high as a 41% rate.[15] If applied to the statistics provided by the midwives, this would mean an average of an additional 2-3 obstetrics referrals per midwife per month. The need for increased human resources is also supported by the 2006 World Health Report, which estimated that an additional 1.5 million health care workers would be needed in Africa to meet the health care demands.[16] In fact, 36 out of the 46 countries in Africa were identified as having a “critical shortage” of doctors, nurses and midwives.[16]

Conclusions and Global Health Implications

Improvement of ANC rates and diagnostic capabilities through ultrasound will contribute toward reaching the Millennium Development Goal 4, 5 and 6 of reducing childhood mortality, improving maternal health and reducing maternal to child transmission of HIV.[17] This study highlights the lack of ultrasound as a significant barrier in the obstetrical care of patients in rural Uganda. The midwives’ self-assessment revealed a complete absence of ultrasound training in midwifery education and significant knowledge deficits in the management of prenatal conditions primarily diagnosed with ultrasound. This information prompted that the midwives who were to receive ultrasound machines at their clinics not only receive extensive formal ultrasound training, but also a “Field Guide” with concise information on the key management points for each condition mentioned in the survey. Additionally, a team of five United States physicians is planning to travel to Uganda in January 2017 to teach Advanced Life Support in Obstetrics (ALSO) and Helping Babies Survive (HBS) courses to the 12 midwives. During that time, it is planned that the midwives will receive refresher training in the use of the ultrasound machines. Follow-up of this cohort of health facilities and midwives should be performed to assess the impact on ANC attendance rates, maternal and fetal mortality rates. This project of equipping health facilities with ultrasound machines and training midwives on obstetrical ultrasound use is a cost effective way to significantly improve maternal and child health in Uganda and perhaps other similar regions. With continued availability of funding and success, Rad Impact will continue to facilitate the distribution of more ultrasound machines and annual training of more midwives to improve care for both pregnant women and their babies.