Health professionals’ experiences and views on obstetric ultrasound in Tanzania: A cross-sectional study

doi:10.21203/rs.3.rs-3750375/v1

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Health professionals’ experiences and views on obstetric ultrasound in Tanzania: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-3750375/v1

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Background

Obstetric ultrasound has been suggested to play an important role in increasing antenatal care attendance in low-income countries. The overall aim of this study was to explore health professionals’ perspectives on different aspects of obstetric ultrasound in Tanzania. More specifically, we wanted to investigate self-reported skills in performing ultrasound examinations and what health professionals thought could improve access to and utilisation of obstetric ultrasound in the clinical setting.

Material and Methods

Data collection took place between November and December 2017 using a questionnaire based on previous qualitative research results from the CROss Country UltraSound Study (CROCUS Study). In total, 17 healthcare facilities from national, regional and district levels, in five urban and semiurban municipalities in the Dar-es-Salaam region were included. A total of 636 health professionals participated in the study (physicians, n=307 and midwives/nurses, n=329).

Results

Most health professionals in this study agreed or strongly agreed that obstetric ultrasound was decisive in the clinical management of pregnancy. Compared to midwives/nurses, a greater proportion of physicians rated their skills as intermediate or high regarding basic ultrasound examinations. Most health professionals reported no skills or low-level skills for assessing cervical length, the fetal heart: 4 chamber view, aorta, and pulmonary artery, and Doppler: umbilical artery. Access to and utilisation of obstetric ultrasound was generally believed to be improved with more and better ultrasound machines along with more training. Compared to midwives/nurses, physicians were significantly more likely to agree or strongly agree that utilisation would improve however, with more ultrasound machines (OR 2.13; 95% CI 1.26 – 3.61), better quality of ultrasound machines (OR 2.27; 95% CI 1.10 – 4.69), more training for health professionals currently performing ultrasound (OR 2.11; 95% CI 1.08 – 4.17), and more physicians trained in ultrasound (OR 2.51; 95% CI 1.30 – 4.87).

Conclusions

Provision of obstetric ultrasound examinations in Tanzania would likely improve with more and better-quality ultrasound machines, more training for health professionals currently performing ultrasound, and overall, more physicians trained in ultrasound use. To increase the accessibility and utilisation of obstetric ultrasound in maternity care in Tanzania, training for midwives in basic obstetric ultrasound use is warranted.

obstetric ultrasound

pregnancy

health professionals

clinical management

Tanzania

cross-sectional study

maternal healthcare

Antenatal care (ANC) plays an important role in reducing the risk of pregnancy-related complications as well as decreasing maternal and child mortality (1). Since 2016, the World Health Organisation (WHO) has recommended that all pregnant women should have a minimum of eight contacts with a health provider during pregnancy, as well as one obstetric ultrasound examination before 24 weeks of gestation, to improve maternal, fetal, and neonatal outcomes (2).

Obstetric ultrasound is routinely offered to expectant mothers in high-income countries (HIC). It is primarily used to determine gestational age, single/multiple pregnancy, placental localisation and fetal anomaly, and later in pregnancy, it is used as a method for surveillance of fetal growth and other pregnancy-related complications (3, 4). Evidence suggests that obstetric ultrasound may improve patient management (5), and in low-income countries (LIC), it appears to play an important role in increasing ANC attendance and in motivating pregnant women to deliver at a healthcare facility (6). In the last decade, obstetric ultrasound has become more commonly used in LIC (3) despite barriers such as ultrasound equipment being costly, and the lack of training and insufficient skills of sonographers and physicians (7, 8). Moreover, the reduction in the size, cost, portability, and robustness of ultrasound equipment has undoubtedly increased the interest in the use of obstetric ultrasound to improve pregnancy-related outcomes in LIC (9-11).

An increase in the utilisation of maternal care services has been shown to correspond to a steady decline in maternal mortality in Sub-Saharan African countries (12). However, due to the lack of infrastructure, qualified medical personnel and poor access to care, maternal mortality remains high in most LIC (13). The quality of ANC in Tanzania remains compromised mostly due to sub-optimal care in terms of labour monitoring, poor documentation, infrastructure and compliance, referral delays, treatment, follow-ups, and shortage of skilled personnel and medical equipment (14-18). Nevertheless, more than 50% of women attended at least four ANC visits during their pregnancy in 2016, an increase of almost 10% compared to 2010 (19). Despite progress toward the United Nations (UN) Millennium Development Goals (MDGs) with a steady decline in maternal mortality rate (MMR) between the years 2000 and 2017, the MMR still stands at 554 per 100 000 live births in Tanzania (20).

Except for larger referral hospitals, most public healthcare facilities in Tanzania do not have access to ultrasound (personal comment Matilda Ngarina 2022). Nevertheless, ultrasound examinations are available at larger hospitals and private clinics in urban areas at the woman's expense (personal comment Matilda Ngarina 2022). We have previously reported that even though obstetric ultrasound plays an important role in the medical management of complicated pregnancy and childbirth in Tanzania, physicians revealed concerns regarding ultrasound equipment and proficiency in ultrasound examination and interpretation of ultrasound images (21).

Aims
Overall aim
The overall aim of this study was to explore Tanzanian health professionals’ perspectives on different aspects of obstetric ultrasound.

Specific aims
More specifically, we wanted to investigate health professionals’ views regarding the role of obstetric ultrasound in the clinical management of pregnancy and their access to obstetric ultrasound. In addition, we also aimed to investigate how health professionals assess their skills in performing obstetric ultrasound examinations and what they believe would improve the utilisation of obstetric ultrasound in the clinical setting. This study is part of the CROss Country UltraSound Study (CROCUS Study) investigating health professionals’ experiences and views of obstetric ultrasound in high-, middle-, and low-income countries (21-33).

The Tanzanian setting

Tanzania is located in the eastern part of sub-Saharan Africa within the African Great Lakes Region. Over 100 languages are spoken in Tanzania. However, 90% speak Swahili as a second language, and many educated Tanzanians speak English. Tanzania is a large country of almost 1 million square kilometres, and according to the 2012 census, the Tanzanian population was 44.9 million (19). Life expectancy was 66 years for men (34) and 68 years for women (35) in 2021. The Tanzanian health system is decentralized, with health services divided into three levels: national, regional, and district levels. The pyramidal referral structure of types of services are as follows (arranged from the bottom and up): Dispensaries and Health Centres, District Hospitals, Regional Referral Hospitals, and National and Specialised Hospitals (Figure 1). The number of physicians and midwives/nurses in Tanzania was estimated in 2018 to be 0.1 and 0.6 per 1000 population, respectively, which is among the lowest rates in the world (36, 37). Today, there are four government health insurance schemes along with multiple private options. The number of gynaecologists/obstetricians in Tanzania was estimated to be 250 in 2020, according to the Association of Gynaecologists and Obstetricians of Tanzania (personal communication from author MA). A majority of childbirths in Tanzania are assisted by a skilled health provider, and skilled birth assistance has increased from 51% in 2010 to 64% in 2015-16 (19).

Study design

This cross-sectional study used a structured questionnaire to investigate several research questions pertaining to obstetric ultrasound in a representative sample of obstetricians/gynaecologists/physicians and midwives/nurses providing antenatal, intrapartum, and postpartum care to women in the Dar-es-Salaam region in Tanzania.

Questionnaire

The questionnaire was developed utilising previous qualitative research results from the CROCUS Study (21-32) and was originally developed in English by the research team. The questionnaire included 105 items, i.e., statements and questions. All items had fixed or Likert-scale response options. Apart from sociodemographic characteristics, questions regarding access, utilisation, and the role of obstetric ultrasound in the clinical management of pregnancy were included, as well as a self-assessment of skills in performing obstetric ultrasound examinations. The questionnaire was translated into Swahili; however, most educated Tanzanians speak English. Therefore it was decided to use the questionnaire originally developed in English. A few adjustments to the original questionnaire were made to better reflect the clinical setting in Tanzania (current profession and current workplace and clarification about how to respond to the questions). To assess understanding and the relevance and appropriateness of the questions and statements, the questionnaire was pilot-tested with one obstetrician/gynaecologist, two resident physicians, two intern physicians, and five midwives, and all found the questions pertinent and interesting.

Study participants

Eligible participants were obstetricians/gynaecologists/physicians and midwives/nurses who worked with obstetric ultrasound examinations or applied results of obstetric ultrasound in clinical practice in healthcare centres and hospitals in the Dar-es-Salaam region. General physicians (GP) were invited to participate in the study since they are responsible for the majority of obstetric ultrasound examinations. Nurses were also invited to participate since they care for a significant portion of women during pregnancy and birth, as the number of midwives in Tanzania is limited. No eligible participants declined participation in the study. In total, 638 health professionals agreed to fill out the questionnaire and returned it to the data collector. Two questionnaires were lost in the PDF transfer process, thus the primary sample consisted of 636 participants.

Data collection and validity of data

Four data collectors collected data from November to December 2017, supervised in pairs by an experienced Tanzanian senior researcher (authors MN or MA). The two Swedish researchers (authors CB and IM) assisted with the data collection during its initial phase. All data collectors were trained by the research team prior to the data collection. Questions and statements in the questionnaire were discussed to ensure correct understanding. The directors of all study sites in the Dar-es-Salaam region were contacted by one of the two Tanzanian researchers (authors MN and MA) to facilitate appointments for potential study participants to meet with the researchers and to receive information about the study. Purposive sampling of healthcare facilities in five urban and semi-urban municipalities in the Dar-es-Salaam region was used to obtain a representative sample of health professionals. The municipal regions included were Ilala, Kinondoni, Ubungo, Temeke, and Kigamboni. In total, 17 healthcare facilities were included (one National Hospital, one Zonal hospital (private), three Regional Referral Hospitals, three District Hospitals (two private), one Poly Clinic (private), and seven Health Centres (one private), and one Dispensary. Participants were recruited at their workplace. Each questionnaire was labelled with a unique identification number and a health facility code. No personal identifying data were collected ensuring the anonymity of the participants. The completed questionnaires were scanned into PDF files to be transferred to Sweden, where an administrator manually entered data into the IBM SPSS Statistic 26 software package. The quality of data entry was evaluated by one author (CB) re-entering every 10^th questionnaire, and the error rate was calculated to be 1.9%. All original questionnaires are stored in a secure, locked location at Muhimbili National Hospital and all the scanned questionnaires are stored on a USB memory stick in a locked location at Umeå University.

Sample size and power

Previous publications regarding the outcomes under study are limited in the scientific literature. Therefore, the calculation of sample size was performed through estimated prevalence based on background characteristics and outcome variables. For the outcome requiring the largest sample size ‘Maternal health interest should always be prioritised over fetal health interest in care’, a sample of 291 obstetricians/physicians and the same number of midwives/nurses (n=291), working in hospital and healthcare centres, was estimated to detect a difference in the proportion of 0.10 with the power of 80% and a significance level of 5%.

Independent variables

All questionnaires were dated, and the mean age of participants was calculated as a continuous variable by subtracting the year of birth from January 1, 2017. Gender was dichotomised as female or male. Current healthcare profession included the response options: obstetrician/gynaecologist, general practitioner, resident physician, physician other (please specify), midwife, nurse, radiologist/sonographer, and other (please specify). The variable current healthcare profession was dichotomised into 1) physicians including obstetrician/gynaecologist, general practitioner, resident physician, radiologist/sonographer, and physician other, and 2) midwife/nurse. In addition, one assistant medical officer (AMO) and one clinical officer (CO) participated in the survey and were categorised as physicians. The healthcare facility level was categorised as Dispensaries or Health Centres, District hospitals, Regional Referral Hospital, Zonal Hospitals, and National Hospitals (Figure 1) where one Dispensary and one Health Centre were considered faith-based. Type of healthcare services was classified as public, private, and both public and private.

Dependent variables

Dependent variables investigating health professionals’ views regarding the role, access, skills, and utilisation of obstetric ultrasound are presented in Table 1. Variables concerning health professionals’ views on access to obstetric ultrasound and training are presented on a 5-point Likert-point scale with the response options: 1) strongly agree, 2) agree, 3) neutral, 4) disagree, and 5) strongly disagree. Response options for dependent variables concerning self-reported skills for specified obstetric ultrasound examinations were dichotomised into “No skills to Low skill level” and “Intermediate to High skill level”. Health professionals’ views regarding dependent variables investigating factors that may improve the utilisation of obstetric ultrasound were dichotomised into “Not at all or Not very much” and “A fair amount or A great deal”.

Table 1. Dependent variables and their response options in the questionnaire

Statements or questions in the questionnaire

Response options in the questionnaire

How do you rate your skills in relation to the assessment/evaluation of:

Fetal presentation
Localisation of placenta
Fetal heartrate
Amount of amniotic fluid
Gestational age; estimated by CRL (crown-rump-length)
Gestational age estimated by biparietal diameter, femur and abdominal diameter
Cervical length
Fetal heart; four-chamber-view
Doppler; umbilical artery

No skills

Low skills

Intermediate skills

High skills

Do you have a role in decision making regarding clinical management on the basis of obstetric ultrasound?

Yes, a minor role

Yes, a moderate role

Yes, a major role

How often do you make decisions based on the results from obstetric ultrasound examinations in your clinical work?

Never

On a daily basis

On a weekly basis

On a monthly basis

More rarely than on a monthly basis

What do you believe would help improve the utilisation of ultrasound at your clinic/workplace?

More ultrasound machines
Better quality of ultrasound machines
More training for health professionals currently performing ultrasound
More doctors trained in ultrasound
More midwives trained ultrasound

Not at all

Not very much

A fair amount

A great deal

Don’t know

Statements on ultrasound resources and training

Pregnant women in my country have access to dating ultrasound (i.e. estimation of gestational age)
Pregnant women in my country have access to fetal anomaly screening
Pregnant women in my country have access to obstetric ultrasound independent of area of living
Pregnant women in my country have access to obstetric ultrasound independent of income
There are enough resources in my country to provide medically indicated obstetric ultrasound examinations to pregnant women who need it
At my workplace, there is always access to obstetric ultrasound when it is needed
At my workplace, lack of ultrasound training of the ultrasound operator sometimes leads to suboptimal pregnancy management
Maternity care in my country would improve if midwives were qualified to perform basic ultrasound

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

Statistical methods

Descriptive statistics were used for sociodemographic data where categorical data are presented with proportions and continuous variables are presented with mean values and standard deviation (SD). Pearson Chi-Square test for categorical data and the independent Student’s t-test were used for continuous data when testing for differences between groups. Univariate logistic regression analysis was used to calculate the odds ratio (OR) and 95% confidence intervals (CI). Statistical significance was set at p<0.05 for all analyses. IBM SPSS Statistics 26 software package was used.

Background characteristics of the study sample

A total of 636 questionnaires were included in the analysis, and the distribution of health professionals was: obstetricians/gynaecologists (n = 21), general practitioners (n = 207), resident physician (n = 32), radiologist/sonographer (n = 25), physician “other” (n = 20), midwife (n = 277), nurse (n = 52), assistant medical officer (AMO) (n = 1), and clinical officer (CO) (n = 1). The majority of participants were female (64.8%). The vast majority of midwives/nurses were female (85%), and 56.9% of physicians were male. The mean age across gender was 37.3 years (SD 9.1). Most participants were married/cohabiting (70.5%) and more than 75% reported having children. Almost all reported having a religious faith (97.6%). Among participants, mean years in the profession and mean years in healthcare were 10.4 (SD 8.7) and 11.7 (SD 9.3), respectively (Table 2). Most health professionals worked in the public sector and healthcare centres (72.0%), providing antenatal, intrapartum, and postpartum care, while 13.8% were not providing maternity care at the time of the survey (Fig. 2). Most participants worked in District, Regional, National, or Faith-based hospitals (Fig. 3).

Table 2. Descriptive information about the study sample and comparisons between physicians and midwives/nurses
				p-value*
	All health professionals	Physicians	Midwives/nurses	X²	F
	N=636	n=307	n=329

Gender	*633 (99.5)*	*306 (99.7)*	*327 (99.4)*
Male	223 (35.2)	174 (56.9)	49 (15.0)	<0.001
Female	410 (64.8)	132 (43.1)	278 (85.0)	<0.001
Age	*631 (99.2)*	*306 (99.7)*	*325 (98.8)*
Mean; SD^a	37.3; 9.1	35.7; 8.2	38.8; 9.6		0.002
Min - Max	22 - 69	24 - 67	22 - 69		0.002
Marital status	*633 (99.2)*	*307 (100)*	*326 (99.1)*
Married/cohabiting	433 (68.4)	199 (64.8)	234 (71.8)	<0.001
Cohabiting	13 (2.1)	5 (1.6)	8 (2.5)
Separated/divorced	16 (2.5)	3 (1.0)	13 (4.0)
Widowed	16 (2.5)	2 (0.7)	14 (4.3)
Not married/single	155 (24.5)	98 (31.9)	57 (17.5)
Children	*627 (98.6)*	*302 (98.4)*	*325 (98.8)*
Yes	476 (75.9)	217 (71.9)	259 (78.7)	0.02
No	151 (24.1)	85 (28.1)	66 (20.3)	0.02
Do you have a religious faith (any religion)?	*609 (95.8)*	*304 (98.4)*	*320 (97.3)*
Yes	609 (97.6)	298 (98.0)	311 (97.2)	0.72
No	6 (1.0)	2 (0.7)	4 (1.3)
I prefer not to answer this question	9 (1.4)	4 (1.3)	5 (1.6)
Years in profession	*626 (98.4)*	*302 (98.4)*	*324 (98.5)*
Mean; SD^a	10.4; 8.7	8.0: 7.6	12.6; 9.1		<0.001
Min - Max	0 - 39	0 - 36	0 - 39		<0.001
Years in healthcare	*630 (99.1)*	*306 (99.7)*	*324 (98.5)*
Mean; SD^a	11.7; 9.3	9.4; 8.2	13.3; 9.8		<0.001
Min - Max	0 - 42	0 - 36	0 - 42		<0.001
Public/private health care	*633 (99.5)*	*305 (99.3)*	*328 (99.7)*
Public	456 (72.0)	242 (79.3)	214 (65.2)	<0.001
Private	115 (18.2)	40 (13.1)	75 (22.9)
Both public and private	62 (9.8)	23 (7.5)	39 (11.9)
Performing ultrasound	*627 (98.6)*	*302 (98.4)*	*325 (98.8)*
Yes	141 (22.5)	102 (33.8)	39 (12.0)	<0.001
No	486 (77.5)	200 (66.2)	286 (88.0)	<0.001
Do midwives perform ultrasound at your workplace?	*611 (96.1)*	*301 (98.0)*	*310 (94.2)*
Yes	126 (20.6)	45 (15.0)	81 (26.1)	0.001
No	450 (73.6)	234 (77.7)	216 (69.7)
Don't know	35 (5.7)	22 (7.3)	13 (4.2)
How often do you perform obstetric ultrasound examinations?	*141 (22.2)*	*101 (32.9)*	*40 (12.2)*
On a daily basis	74 (52.5)	58 (57.4)	16 (40.0)	0.30
On a weekly basis	23 (16.3)	15 (14.9)	8 (20.0)
On a monthly basis	7 (5.0)	4 (4.0)	3 (7.5)
More rarely than on a monthly basis	37 (26.2)	24 (23.8)	13 (32.5)
Those days you perform obstetric ultrasound examinations, estimate the average number of examinations	*126 (19.8)*	*93 (14.6)*	*33 (0.05)*
Mean; SD^a	10.9; 10.3	11.3; 10.6	9.7; 9.1		0.82
Min - Max	0 - 75	1 - 75	0 - 35		0.82
Do you have a role in decision-making regarding clinical management on the basis of obstetric ultrasound examinations?	*631 (99.2)*	*306 (99.7)*	*325 (98.8)*
No	127 (20.1)	27 (8.8)	100 (30.8)	<0.001
Yes, a minor role	107 (17.0)	33 (10.8)	74 (22.8)
Yes, a moderate role	198 (31.4)	83 (27.1)	115 (35.4)
Yes, a major role	199 (31.5)	163 (53.3)	36 (11.1)
How often do you make decisions based on the results from obstetric ultrasound examinations in your clinical work?	*629 (98.9)*	*306 (99.7)*	*323 (98.2)*
Never	111 (17.6)	15 (4.9)	96 (29.7)	<0.001
On a daily basis	385 (61.2)	229 (74.8)	156 (48.3)
On a weekly basis	35 (5.6)	24 (7.8)	11 (3.4)
On a monthly basis	13 (2.1)	6 (2.0)	7 (2.2)
More rarely than on a monthly basis	85 (13.5)	32 (10.5)	53 (16.4)

Numbers in parenthesis are percentages unless otherwise specified.
^a Standard deviation
* Significance test p<0.05

Table 3. Health professionals' views of access to ultrasound and training analysed by univariate logistic regression using physicians as the reference group

	Physicians¹	Midwives/nurses	p-value*	OR	CI (9%)	p-value*
	n=307	n=329	X²

Pregnant women in my country have access to dating ultrasound (i.e. estimation of gestational age)	*306 (99.7)*	*324 (98.5)*
Strongly agree	79 (25.8)	80 (24.7)	<0.001
Agree	122 (39.9)	165 (50.9)
Neutral	30 (9.8)	42 (13.0)		2.47	1.60 - 3.82	<0.001
Disagree	61 (19.9	25 (7.7)
Strongly disagree	14 (4.6)	12 (3.7)
Pregnant women in my country have access to fetal anomaly screening	*304 (99.0)*	*319 (97.0)*
Strongly agree	38 (12.5)	35 (11.0)	<0.001
Agree	92 (30.3)	145 (45.5)
Neutral	51 (16.8)	45(14.1)		1.81	1.28 - 2.57	<0.001
Disagree	75 (24.7)	72 (22.6)
Strongly disagree	48 (15.8)	22 (6.9)
Pregnant women in my country have access to obstetric ultrasound independent of area of living	*304 (99.0)*	*323 (98.2)*
Strongly agree	52 (17.1)	55 (17.0)	0.006
Agree	99 (32.6)	139 (43.0)
Neutral	36 (11.8)	48 (14.9)		1.86	1.30 - 2.65	<0.001
Disagree	81 (26.6)	57 (17.6)
Strongly disagree	36 (11.8)	24 (7.4)
Pregnant women in my country have access to obstetric ultrasound independent of income	*305 (99.3)*	*324 (98.5)*
Strongly agree	56 (18.4)	48 (14.8)	<0.001
Agree	79 (25.9)	139 (42.9)
Neutral	33 (10.8)	49 (15.1)		2.16	1.52 - 3.05	<0.001
Disagree	91 (29.8)	72 (22.2)
Strongly disagree	46 (15.1)	16 (4.9)
There are enough resources in my country to provide medically indicated obstetric ultrasound examinations to pregnant women who need it	*306 (99.7)*	*323 (98.2)*
Strongly agree	9 (2.9)	16 (5.0)	<0.001
Agree	29 (9.5)	54 (16.7)
Neutral	32 (10.5)	61 (18.9)		2.64	1.46 - 3.51	<0.001
Disagree	126 (41.2)	121 (37.5)
Strongly disagree	110 (35.9)	71 (22.0)
At my workplace, there is always access to obstetric ultrasound when it is needed	*306 (99.7)*	*322 (97.9)*
Strongly agree	77 (25.2)	74 (23.0)	0.97
Agree	158 (51.6)	173 (53.7)
Neutral	22 (7.2)	25 (7.8)		1.03	0.67 - 1.59	0.89
Disagree	38 (12.4)	38 (11.8)
Strongly disagree	11 (3.6)	12 (3.7)
At my workplace, lack of ultrasound training of the ultrasound operator sometimes leads to subopitmal pregnancy management	*305 (99.3)*	*323 (92.2)*
Strongly agree	79 (25.9)	84 (26.0)	0.82
Agree	137 (44.9)	142 (44.0)
Neutral	38 (12.5)	35 (10.8)		0.86	0.57 - 1.30	0.48
Disagree	38 (12.5)	42 (13.0)
Strongly disagree	13 (4.3)	20 (6.2)
Maternity care in my country would improve if midwives were qualified to perform basic ultrasound examinations	*305 (99.3)*	*325 (98.8)*
Strongly agree	131 (43.0)	156 (48.0)	0.05
Agree	140 (45.9)	123 (37.8)
Neutral	21 (6.9)	20 (6.2)		0.52	0.30 - 1.02	0.06
Disagree	6 (2.0)	19 (5.8)
Strongly disagree	7 (2.3)	7 (2.2)

Numbers in parenthesis are percentages unless otherwise specified.
¹ Reference group
* Significance test p<0.05

Table 4. Self-rated skills for specific obstetric ultrasound examinations

How do you rate your skills in ultrasound in relation to the assessment/evaluation of:	Fetal presentation			Localisation of the placenta
	Fetal presentation			Localisation of the placenta
	No to low skill level	Intermediate to high skill level	p-value*	No to low skill level	Intermediate to high skill level	p-value*
Health profession
Physicians	7 (6.7)	97 (93.3)	<0.001	19 (18.4)	84 (81.6)	<0.001
Midwives/nurses	14 (32.6)	29 (67.4)	<0.001	20 (48.8)	21 (51.2)	<0.001
Public/private health care
Public	12 (12.0)	88 (88.0)	0.36	26 (26.5)	72 (73.5)	0.87
Private	5 (16.7)	25 (83.3)		9 (31.0)	20 (69.0)
Both public and private	4 (25.0)	12 (75.0)		4 (25.0)	12 (75.0)
Performing ultrasound
Yes	19 (13.7)	120 (86.3)	0.37	35 (25.7)	101 (74.3)	0.13
No	2 (25.0)	8 (75.0)	0.37	4 (50.0)	4 (50.0)	0.13

How do you rate your skills in ultrasound in relation to the assessment/evaluation of:	Fetal heart rate			The assessment/evaluation of amount of amniotic fluid
	Fetal heart rate			The assessment/evaluation of amount of amniotic fluid
	No to low skill level	Intermediate to high skill level	p-value*	No to low skill level	Intermediate to high skill level	p-value*
Health profession
Physicians	8 (7.7)	96 (92.3)	0.009	23 (22.3)	80 (77.7)	<0.001
Midwives/nurses	10 (23.3)	33 (76.7)	0.009	22 (51.2)	21 (48.8)	<0.001
Public/private health care
Public	13 (13.0)	87 (87.0)	0.91	31 (31.0)	69 (69.0)	0.81
Private	3 (10.0)	27 (90.0)		10 (34.5)	19 (65.5)
Both public and private	2 (12.5)	14 (87.5)		4 (25.0)	12 (75.0)
Performing ultrasound
Yes	17 (12.2)	122 (87.8)	0.98	40 (29.0)	98 (71.0)	0.046
No	1 (12.5)	7 (87.5)	0.98	5 (62.5)	3 (37.5)	0.046

How do you rate your skills in ultrasound in relation to the assessment/evaluation of:	Gestational age estimated by CRL (crown-rump-length)			Gestational age estimated by biparietal diameter, femur length and abdominal diameter
	Gestational age estimated by CRL (crown-rump-length)
	No to low skill level	Intermediate to high skill level	p-value*	No to low skill level	Intermediate to high skill level	p-value*
Health profession
Physicians	41 (39.4)	63 (60.6)	0.52	26 (25.0)	78 (75.0)	<0.001
Midwives/nurses	19 (45.2)	23 (54.8)	0.52	26 (61.9)	16 (38.1)	<0.001
Public/private health care
Public	43 (43.0)	57 (57.0)	0.70	34 (34.0)	66 (66.0)	0.19
Private	10 (34.5)	19 (65.5)		14 (46.7)	16 (53.3)
Both public and private	7 (43.8)	9 (56.3)		3 (20.0)	12 (80.0)
Performing ultrasound
Yes	54 (39.1)	84 (60.9)	0.045	46 (33.3)	92 (66.7)	0.017
No	6 (75.0)	2 (25.0)	0.045	6 (75.0)	2 (25.9	0.017

How do you rate your skills in ultrasound in relation to the assessment/evaluation of:	Cervical length			Fetal heart: 4 chamber view
	Cervical length			Fetal heart: 4 chamber view
	No to low skill level	Intermediate to high skill level	p-value*	No to low skill level	Intermediate to high skill level	p-value*
Health profession
Physicians	53 (51.0)	51 (49.0)	0.81	53 (51.0)	51 (49.0)	0.28
Midwives/nurses	20 (48.8)	21 (51.2)	0.81	25 (61.0)	16 (39.0)	0.28
Public/private health care
Public	53 (53.0)	47 (47.0)	0.35	53 (53.5)	46 (46.5)	0.82
Private	11 (37.9)	18 (62.1)		15 (50.0)	15 (50.0)
Both public and private	8 (53.3)	7 (46.7)		9 (60.0)	6 (40.0)
Performing ultrasound
Yes	69 (50.4)	68 (49.6)	0.98	70 (51.1)	67 (48.9)	0.007
No	4 (50.0)	4 (50.0)	0.98	8 (100.0)	-	0.007

How do you rate your skills in ultrasound in relation to the assessment/evaluation of:	Fetal heart: aorta and pulmonary artery			Doppler: umbilical artery
	Fetal heart: aorta and pulmonary artery			Doppler: umbilical artery
	No to low skill level	Intermediate to high skill level	p-value*	No to low skill level	Intermediate to high skill level	p-value*
Health profession
Physicians	63 (60.6)	41 (39.4)	0.63	63 (60.6)	41 (39.4)	0.62
Midwives/nurses	26 (65.0)	14 (35.0)	0.63	23 (56.1)	18 (43.9)	0.62
Public/private health care
Public	60 (60.6)	39 (39.4)	0.60	57 (57.6)	42 (42.2)	0.49
Private	17 (58.6)	12 (41.4)		17 (56.7)	13 (43.3)
Both public and private	11 (73.3)	4 (26.7)		11 (73.3)	4 (26.7)
Performing ultrasound
Yes	82 (60.3)	54 (39.7)	0.12	80 (58.4)	57 (41.6)	0.35
No	7 (87.5)	1 (12.5)	0.12	6 (75.0)	2 (25.0)	0.35

Numbers in parenthesis are percentages unless otherwise specified.
* Significance test p<0.05

Table 5. Factors that may improve utilisation of obstetric ultrasound analysed by univariate logistic regression

	More ultrasound machines						Better quality of ultrasound machines
	More ultrasound machines						Better quality of ultrasound machines
	Not at all or Not very much	A fair amount or A great deal	p-value*	OR	CI (95%)	p-value*	Not at all or Not very much	A fair amount or A great deal	p-value*	OR	CI (95%)	p-value*
Health profession
Midwives/nurses	48 (15.2)	267 (84.8)		1			25 (8.0)	287 (92.0)		1
Physicians	23 (7.8)	273 (92.2)	0.004	2.13	1.26 - 3.61	0.005	11 (3.7)	286 (96.3)	0.02	2.27	1.10 - 4.69	0.03
Public/private health care
Private	23 (21.5)	84 (78.5)		1			14 (13.0)	94 (87.0)		1
Public	39 (8.8)	406 (91.2)	<0.001	0.35	0.20 - 0.62	<0.001	20 (4.6)	419 (95.4)	0.003	0.32	0.16 - 0.66	0.002
Performing ultrasound
No	49 (10.1)	416 (89.5)		1			24 (5.2)	439 (94.8)		1
Yes	21 (15.3)	116 (84.7)	0.12	0.65	0.38 - 1.13	0.13	12 (8.8)	125 (91.2)	0.12	0.57	0.28 - 1.71	0.13

	More training for health professionals currently performing ultrasound						More physicians trained in ultrasound
							More physicians trained in ultrasound
	Not at all or Not very much	A fair amount or A great deal	p-value*	OR	CI (95%)	p-value*	Not at all or Not very much	A fair amount or A great deal	p-value*	OR	CI (95%)	p-value*
Health profession
Midwives/nurses	28 (8.8)	290 (91.2)		1			33 (10.4)	285 (89.6)		1
Physicians	13 (4.4)	285 (95.6)	0.03	2.11	1.08 - 4.17	0.03	13 (4.4)	282 (95.6)	0.005	2.51	1.30 - 4.87	0.006
Public/private health care
Private	11 (10.0)	99 (90.0)		1			18 (16.4)	92 (83.6)		1
Public	24 (5.4)	419 (94.6)	0.13	0.52	0.24 - 1.09	0.08	23 (5.2)	416 (94.8)	<0.001	0.28	0.15 - 0.55	<0.001
Performing ultrasound
No	29 (6.1)	444 (93.9)		1			34 (7.3)	433 (92.7)		1
Yes	11 (8.1)	125 (91.9)	0.42	0.74	0.36 - 1.53	0.42	12 (8.8)	125 (91.2)	0.57	0.82	0.41 - 1.63	0.57

	(More) midwives trained in ultrasound
	(More) midwives trained in ultrasound
	Not at all or Not very much	A fair amount or A great deal	p-value*	OR	CI (95%)	p-value*
Health profession
Midwives/nurses	30 (9.4)	288 (90.6)		1
Physicians	25 (8.5)	270 (91.5)	0.68	1.13	0.65 - 1.96	0.68
Public/private health care
Private	17 (15.7)	91 (84.3)		1
Public	34 (7.7)	408 (92.3)	0.03	0.45	0.24 - 0.83	0.01
Performing ultrasound
No	42 (9.0)	426 (91.0)		1
Yes	13 (9.6)	123 (90.4)	0.84	0.93	0.49 - 1.79	0.84

Numbers in parenthesis are percentages unless otherwise specified.
* Significance test p<0.05

The role of obstetric ultrasound

Most participants (77.5%), with 88% of midwives/nurses and 66.2% of physicians, reported not performing obstetric ultrasound, however, of those who were performing obstetric ultrasound, 57.4% (n = 58) of physicians and 40% (n = 16) of midwives/nurses performed obstetric ultrasound daily, with a mean number of obstetric ultrasound examinations of 10.9 (SD 10.3) per day (Table 2). Over 50% (n = 163) of physicians reported having a major role in decision-making regarding clinical management based on obstetric ultrasound, while 35.4% (n = 115) of midwives/nurses reported having a moderate role in clinical management based on obstetric ultrasound. Over 70% of physicians and 48.3% of midwives/nurses reported making decisions on a daily basis in their clinical work based on the results of an obstetric ultrasound (Table 2).

Insert Table 2 here

Access to obstetric ultrasound

The majority of health professionals agreed or strongly agreed that women in Tanzania have access to dating ultrasound (physicians = 65.7%, midwives/nurses = 75.6%), fetal anomaly screening (physicians = 42.8%, midwives/nurses = 56.6%), independent of the area of residence (physicians = 49.7%, midwives/nurses = 60%) or income (physicians = 44.9%, midwives/nurses = 57.7%), with physicians statistically significantly more likely to agree with the statements compared to midwives/nurses (Table 3). Nevertheless, approximately 70% of health professionals (physicians = 77.1%, midwives/nurses = 59.5%) disagreed or strongly disagreed that there are enough resources in Tanzania to provide medically indicated obstetric ultrasound examinations to pregnant women (Table 3), with physicians twice as likely to disagree or strongly disagree with the statement compared to midwives/nurses (OR 2.64; 95% CI 1.46–3.51). On the other hand, most health professionals agreed or strongly agreed that there was always access to obstetric ultrasound in their workplace when needed (physicians = 76.8%, midwives/nurses = 76.7%), but the lack of ultrasound training sometimes led to suboptimal pregnancy management (physicians = 70.8%, midwives/nurses = 70%). Nearly 90% of health professionals agreed or strongly agreed that maternity care would improve if midwives were qualified to perform basic obstetric ultrasound examinations.

Insert Table 3 here

Self-rated skills for specified obstetric ultrasound examinations

Figure 4a shows that most physicians (60–93%) rated their skills as intermediate or high for assessing fetal presentation, localisation of the placenta, fetal heart rate, amniotic fluid, gestational age estimated by crown-rump-length (CRL) and gestational age by biparietal diameter (BPD), femur length (FL), and abdominal circumference (AC), compared to 50–77% of midwives/nurses (Fig. 4b) who rated their skills as intermediate or high regarding fetal presentation, localization of the placenta, and heart rate. Generally, a majority of physicians reported no skills to low-level skills regarding the assessment of cervical length (51%), fetal heart: 4 chamber view (51%), aorta and pulmonary artery (60.6%), and Doppler: umbilical artery (60.6%) with corresponding numbers for midwives/nurses: cervical length (48.8%), fetal heart: 4 chamber view (61%), aorta and pulmonary artery (65%), and doppler: umbilical artery (56.1%) with the addition of gestational age: BPD, FL, AC (61.9%), and assessment of amnionic fluid (51.2%), (Table 4).

Insert Table 4 here

Improving utilisation of obstetric ultrasound

Approximately 9 of 10 health professionals reported that utilisation of obstetric ultrasound would improve ‘A fair amount or A great deal’ if there were more ultrasound machines (physicians = 92.2%, midwives/nurses = 84.8% ) and better-quality machines (physicians = 96.3%, midwives/nurses = 92.0% ), more training for health professionals currently performing obstetric ultrasound (physicians = 95.6%, midwives/nurses = 91.2% ), and if there were more physicians (physicians = 95.6%, midwives/nurses = 89.6% ) and midwives (physicians = 91.5%, midwives/nurses = 90.6%) trained in obstetric ultrasound (Table 5). The distribution of answers is shown in more detail in Fig. 5a and Fig. 5b. The numbers were similar for health professionals working in the public or private sector or both, as well as for those performing or not performing obstetric ultrasound (Table 5). Compared to midwives/nurses, physicians were more likely to agree or strongly agree that utilisation would improve with more ultrasound machines (OR 2.13; 95% CI 1.26–3.61), better quality of ultrasound machines (OR 2.27; 95% CI 1.10–4.69), more training for health professionals currently performing ultrasound (OR 2.11; 95% CI 1.08–4.17), and more physicians trained in ultrasound (OR 2.51; 95% CI 1.30–4.87). Compared to health professionals working in the public healthcare sector, health professionals working in private healthcare were significantly less likely to agree or strongly agree that more ultrasound machines (OR 0.35; 95% CI 0.20–0.62), better quality of ultrasound machines (OR 0.32; 95% CI 0.16–0.66), more training for health professionals currently performing ultrasound (OR 0.52; 95% CI 0.24–1.09), and more training of physicians (OR 0.28; 95% CI 0.15–0.55) and midwives/nurses (OR 0.45; 95% CI 0.24–0.83) would improve utilisation of obstetric ultrasound (Table 5).

Insert Table 5 here

This study aimed to explore health professionals’ perspectives on different aspects of obstetric ultrasound examinations in Tanzania. Most health professionals believed that obstetric ultrasound is decisive in the management of pregnancy, and this is congruent with the results from other countries included in the CROCUS Study (21–33). However, only 20% of health professionals working in obstetric care performed obstetric ultrasound examinations themselves. Congruent with the results from the CROCUS Study in Rwanda (33), access to and utilisation of obstetric ultrasound were also believed to be improved with more and better ultrasound machines along with more training of health professionals in obstetric ultrasound.

The development of portable and more robust ultrasound equipment may offer better access to obstetric ultrasound for women in rural areas, helping triage emergencies, decreasing delays in treatment and increasing timely referrals, thus improving pregnancy-related outcomes (9–11, 38, 39). The majority of health professionals felt that improved quality of ultrasound equipment, more training and more ultrasound machines, along with more midwives being qualified to perform obstetric ultrasound, would potentially increase the access to and utilisation of obstetric ultrasound as part of maternity care in Tanzania, although physicians were more likely to hold these views than midwives/nurses. Consistent with the considerable concerns raised about the shortage of ultrasound equipment in the CROCUS qualitative study in Tanzania (21), approximately 70% of health professionals in this study reported a lack of resources to provide medically indicated obstetric ultrasound examinations. However, these results are in apparent contradiction to an agreement with the statement ‘At my workplace, there is always access to obstetric ultrasound when it is needed’, with more than 76% of health professionals agreeing or strongly agreeing with the statement. Additionally, about half of the participants agreed or strongly agreed that women in Tanzania have access to obstetric ultrasound regardless of income and residential area.

The reduction of MMR remains one of the top priorities of the MDGs, and concerted efforts to address the MDGs have contributed to the steady decline of MMR in Sub-Saharan countries (12). Nevertheless, most LICs continue to demonstrate unacceptably high MMRs, and further decrease is limited due to lack of infrastructure and trained health professionals, poor access to care, and lack of screening for early obstetric risks (13). Despite a demonstrated decline in MMR in Tanzania, the current MMR remains high compared to other LIC (20). It has been suggested that a large number of maternal deaths are caused by preventable conditions (40–43) and that there is a need to shift towards improved screening for prevention, early detection, and treatment during pregnancy (44). Even though more than 50% of women in Tanzania attend at least four ANC visits during pregnancy (19), it is still just half of the recommended ANC contacts now advocated by the WHO (2). Increased availability and use of obstetric ultrasound as part of ANC in LIC (3) may lead to an increase in ANC utilisation, improved safety of pregnancy and delivery, more hospital deliveries and thus a reduction of the MMR (6, 45–47), but more recent studies have found that routine ultrasound examinations did not increase ANC utilisation and hospital deliveries for women with pregnancy complications in low- and middle-income countries (LMIC) (46, 48). Instead, overall improvement in the quality of care has been suggested to reduce MMR and improve pregnancy-related outcomes (48). Yet it is important to understand the potential impact of increased availability and utilisation of obstetric ultrasound together with insufficiently trained health professionals in LIC. In some LIC, there have been issues with gender-selective abortions, and although there is no evidence of this in Tanzania, such issues may arise with increased use of obstetric ultrasound (47).

Miller et al. (44) coined the terms ‘too little, too late’ (TLTL) and ‘too much, too soon’ (TMTS), where TLTL indicates inadequate resources or withheld or unavailable care until too late, thus associated with high MMR. In contrast, TMTS implies over-medicalization of normal pregnancy and birth, i.e., unnecessary use of non-evidence-based interventions. TLTL is mainly ascribed to LIC and TMTS to HIC; however, these two extremes can coexist in the same country. Despite the important role of obstetric ultrasound in pregnancy and childbirth, understaffed and underfinanced health systems, with the addition of an ineffective referral system and inadequate infrastructure for obstetric emergencies, will continue to struggle with lack of capacity (49). Consequently, increased access to and utilisation of obstetric ultrasound may be just one, albeit an important piece of the puzzle to improve pregnancy-related outcomes. The whole organisation of the health system may need reform to provide a safe, high-quality, and evidence-based obstetric and neonatal chain of care in LIC (49).

The levels of self-reported obstetric ultrasound skills in this study give an indication regarding ultrasound competence and, indirectly, the level of education and training in obstetric ultrasound (33). Most participants in our study considered themselves to have intermediate to high skills in performing routine obstetric ultrasound examinations. However, most reported no skills to low-level skills regarding more advanced obstetric ultrasound examinations (i.e., fetal heart: 4 chamber view, aorta, pulmonary, and umbilical artery). Nevertheless, over 60% of participants reported making decisions based on obstetric ultrasound examination in their clinical work on a daily basis, with a similar percentage reporting having a moderate to major role in decision-making based on obstetric ultrasound in the clinical management of pregnancy.

Previous findings from the qualitative part of the CROCUS Study in Tanzania indicated that there was a need for further training of physicians in how to operate ultrasound machines and interpret images to increase access and adequate utilisation of obstetric ultrasound (21). In this larger study, insufficient or lack of training was considered to lead to suboptimal management in pregnancy by most health professionals. Previous research has demonstrated that healthcare workers can be effectively trained in basic obstetric ultrasound use and that skills are retained over time (8, 47, 50). In addition, healthcare workers trained in obstetric ultrasound feel more empowered and motivated to screen pregnant women for obstetric risks (47).

Methodological considerations

Previous studies addressing health professionals’ views of obstetric ultrasound are lacking, so our sample size and power calculation were based on the assumption of proportions for outcome variables in relation to background variables. The study achieved a total of 636 participants (n = 307 physicians and n = 329 midwives/nurses), enabling sufficient power for all pre-planned subgroup analyses to be undertaken. We aimed to recruit a representative sample of health professionals, including ultrasound operators and non-operators from public and private healthcare, different level hospitals and healthcare centres. By limiting recruitment to the urban and semiurban Dar-es-Salaam region, we cannot be certain that our sample is representative of the whole of Tanzania. The questionnaire was translated into Swahili, but in the end, only the English version was used (with a few adjustments). Despite pilot testing of the English version and that most educated Tanzanians speak English, it is possible that all participants did not fully understand some questions. Still, none of the invited participants declined participation in this study, and there were few missing responses, suggesting that the questionnaire was relevant and well received by the participants.

Most participating health professionals in Tanzania stated that obstetric ultrasound is decisive in the clinical management of pregnancy and that access to and utilisation of obstetric ultrasound in Tanzania would improve with more and better-quality ultrasound machines. Yet, most health professionals reported inadequate skill levels regarding more advanced obstetric ultrasound examinations. So, in addition to more adequate resources to increase access to and utilisation of obstetric ultrasound to improve the provision of obstetric care in Tanzania, it seems clear that more training of health professionals is also required. And to further improve maternity care in Tanzania, there was also strong support for more midwives to be trained to undertake basic obstetric ultrasound examinations.

AC: Abdominal Circumference

AMO: Assistant Medical Officer

ANC: Antenatal Care

BPD: Biparietal Diameter

CI: Confidence Interval

CO: Clinical Officer

CRL: Crown-Rump-Length

CROCUS: Cross-Country Ultrasound Study

FL: Femur Length

HIC: High-Income Countries

LIC: Low-Income Countries

LMIC: Low- and Middle-Income Countries

MDG: Millennium Development Goals

MMR: Maternal Mortality Rate

OR: Odds Ratio

SD: Standard Deviation

TLTL: Too Little, Too Late

TMTS: Too Much, Too Soon

UN: United Nations

WHO: World Health Organisation

Ethical approval and consent to participate

Ethical approval for this study was obtained from the National Institute for Medical Research and the Ministry of Health, Community Development, Gender, Elderly & Children, Tanzania (Reference: NIMR/HQ/R.8a/Vol. IX/2583). Participation in the study was voluntary. All participants received verbal and written information and signed a consent form prior to filling out the questionnaire.

Consent for publication

Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding
This research was made possible by grants from Umeå University, Västerbotten County Council, the Swedish Research Council, Sweden (2014-2672), the Swedish Research Council for Health, Working Life and Welfare (Forte), and the European Commission under a COFAS Marie Curie Fellowship (2013-2699).

Authors' contributions

CB, IM, MN, MA, HK, KE, SH, RS, JPSS, JN, and PTL designed the study. CB, IM, MN, and MA collected the data. Authors CB and IM performed all the data analysis. All authors contributed to the interpretation of the data. All authors contributed to the writing of the manuscript. RS performed an English language review of the manuscript. All authors read and gave their final approval of the manuscript.

Acknowledgements

We want to take the opportunity to thank all participating health professionals for sharing their experiences and views on the use of obstetric ultrasound. We would also like to thank Eustace Ng’Weshemi, Gilbert Kilonzo, Yvony Kamala, and Madete Masunzu for helping with the data collection and Joanna Larsson for her excellent work with data registration. We acknowledge the support provided by the Ministry of Health, heads of all health facilities, and the Muhimbili University of Health and Allied Sciences in Dar-es-Salaam, Tanzania. We would also like to thank Annika Åhman for participating in the development of the questionnaire and statistician Gabriel Granåsen for statistical support.

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No competing interests reported.

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Health professionals’ experiences and views on obstetric ultrasound in Tanzania: A cross-sectional study

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Abstract

Figures

Background

Material and Method

The Tanzanian setting

Study design

Questionnaire

Data collection and validity of data

Sample size and power

Independent variables

Dependent variables

Statistical methods

Results

Background characteristics of the study sample

The role of obstetric ultrasound

Access to obstetric ultrasound

Self-rated skills for specified obstetric ultrasound examinations

Improving utilisation of obstetric ultrasound

Discussion

Methodological considerations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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