3.1. Characteristics of the study participants
A total of 93 participants including 64 pregnant women and 29 male partners who were accessing ANC services at the time of the study, participated in the FGDs. Among the 64 participating pregnant women, 10 were adolescents aged between 16 to 19 years, 15 belonged to the age range between 20 to 24 years, 4 were between 25 and 29 years of age, 20 were in the age group between 30 and 34, 6 were in the age group between 35 and 39, and 9 were aged 40 years and above. 49 pregnant women were formally married or living with a partner while 15 were single. Of the 49 pregnant married women, 12 were aged between 20-24, 4 were aged between 25-29, 18 were aged between 30-34, 6 were aged between 35-39 and 9 were aged from 40 and above. The single pregnant women were 12 and aged between 16-19. There were 29 male partners aged between 16 and 40 years that took part in the study. 17 were married and 12 were not married, 1 of which was an adolescent.
All information is summarised in table 1 below.
|
Age group
|
Females n(%)
|
Males n(%)
|
|
|
|
|
16-19
|
10(16)
|
1(3)
|
20-24
|
15(23)
|
2(7)
|
25-29
|
4(6)
|
5(17)
|
30-34
|
20(31)
|
4(14)
|
35-39
|
6(9)
|
5(17)
|
40+
|
9(14)
|
12(41)
|
Marital Status
|
|
|
Females
|
|
|
Married
|
49(77)
|
17(59)
|
Single
|
15(23)
|
12(41)
|
scanned
|
47(73)
|
|
Not scanned
|
17(27)
|
|
Table 1: Characteristics of the study participants (n = 93)
All participants were asked to give their perceived facilitators and barriers to the feasibility and acceptability of ultrasound scanning as an intervention in healthcare facilities. The following themes were derived from the data: Perceived Knowledge about ultrasound scanning; and perceived barriers and facilitators to the feasibility and acceptability of ultrasound scanning intervention in healthcare facilities as summarised in Figure 1.
Results
3.2. Perceived knowledge about ultrasound scanning
We invited the participants to provide their own definitions of ultrasound scanning so that we could get a sense of their understanding of the USS procedure. Participants from both urban and rural settings exhibited some awareness of USS services. All participants readily acknowledged their familiarity with ultrasound scanning by discussing how useful it is for assessing the health of the fetus, including the heartbeat, position, exact gestational age, size, number of fetuses, and anticipated due date. Some participants also mentioned how USS aids in determining the gender of the unborn child so that the parents may set up enough money to purchase proper baby clothing. Other participants stated that USS helps to determine any possible fetal abnormalities so that prospective parents are prepared to care for the baby, particularly in the event that it is predicted that the unborn child would be born with some disability. More importantly, the participants came to the same conclusion when they said that, the USS informs people about any issues that might occur during pregnancy, which enables them to get proper medical care and save the life of both the pregnant woman and the unborn child. In a focus group with males, one participant had this to say:
“…What I understand is that a scan is a procedure that a pregnant mother undertakes to check the wellbeing of both the mother and the child. Through the scan, you are able to see if there are any abnormalities with the child if the baby is sitting in the right position…, the due dates, and gender and you also check many other things. Usually, it is from the scan where you check if the baby has got complications or not and seek medical attention if it is needed…” [FGD1/LMUTH].
3.2.1. Knowledge about USS from prior experiences with the uptake of ultrasound scanning by clients
In the quest to further explore participants’ understanding of ultrasound scanning, we sought to know whether they had prior experiences with this service. The majority of the women mentioned that they either had one themselves or witnessed someone undergoing it. The women in the age range of 20 to 35 years said they had at least one scan before, whereas those over 41 years responded that, they never had one because scanning was a relatively new, expensive and scarce technology in their generation. Male participants provided a variety of responses. The older participants (over 40 years) stated that they learned about USS from community radio programs. Those aged 25 to 30 stated that they gained knowledge through ANC health education. The males aged 16 to 24 had no idea because it was their first time attending ANC with their partners who were expecting their first child.
I normally hear people say that the scan reduces your years (life expectancy), that if you keep on going to the scan, your years and your baby will keep on reducing but me I don’t believe in that because I had two before and hear I am…[FGD2/woman/Kanyama]
3.3. Perceived barriers to feasibility and acceptability of ultrasound scanning intervention in the healthcare facilities.
We asked participants to indicate their perceived barriers to feasibility and acceptability of USS intervention in MCH departments within healthcare facilities. Barriers were expressed both at individual and facility levels. They included misconceptions about ultrasound scanning, inadequate materials for USS; lack of clear USS procedural requirements; nurses’ negative attitude towards clients; inability to read and interpret scans; language barrier when interpreting the scans; insensitivity towards clients who wish to know or not to know the sex of the fetus; clients being attended to by trainees and insufficient physical space within healthcare facilities for USS, and irregular schedules for the scans. These perceived barriers led to negative views towards ultrasound scanning services for some participants, who expressed feelings of anxiety, anger, fear, frustration and shame, which ultimately discouraged pregnant women from getting scanned. All factors are explained in detail below.
3.4.1. Perceived Individual barriers
3.4.1.1. Misconceptions about ultrasound scanning
Older male and female participants made it clear that most people in the community view USS as a taboo and it is against their beliefs. According to tradition, a woman is not permitted to display her pregnancy when it is still in the early stages since doing so could give evil people the chance to perform witchcraft on the pregnant woman. They reported alleged instances where prematurely disclosed pregnancies simply vanished. Ultrasound scanning services to diagnosed early stages of pregnancy are therefore not welcome.
“…You see we are Africans and we see these things still happen in our communities and we cannot run away from them they are part of us…some people are really evil they just want to destroy people’s lives so it is dangerous to bring this intervention” … [FGD men Kanyama]
Other myths that were mentioned stemmed from a lack of understanding of how ultrasound equipment functions. Some people believed that ultraviolet radiation damages the developing fetus and later causes mental disorders, cancer in women, and may alter the sex of the child.
“…People warn us that when you are pregnant and you are sent to do a scan, after some months it burns the baby inside there” … [FGD women George]
“…The scans are disturbing the baby's growth so you will find that the baby's brain has been disturbed and the baby will come out mentally ill…[FGD women Chawama]
“We hear from the people in these compounds where we live, that these scans have electricity that destroys the baby's chest,… the baby doesn't grow properly and the baby might come out with big kidneys and other complications…like my mother in law told me that I will give birth to an abnormal child and that's not in our family it's because of this scan... [FGD men Kanyama]
As a result of these accounts, we asked participants to suggest potential strategies to counter misinformation. They pointed out community-based activities to raise awareness on USS and suggested that the nurses adopt positive attitude when handling the clients.
“For this program to work, those community workers that do sensitization in the community should also talk about scanning a lot. They should teach pregnant women the importance of scanning. This will make this program go further…” [FGD men Kanyama]
“…The health workers should receive the pregnant women with care not making them wait for a long time or scorn them…” [FDG women Matero]
3.4.2. Perceived facility barriers
3.4.2.1. Inadequate scanners
In all of the healthcare facilities that took part in the study, ultrasound scanning were performed from the radiology departments. The radiology departments operate on a first come first served basis as such, the department was characterised by long ques, and pregnant women were not prioritised to access USS. There were instances when patients would spend the whole day on the ques without accessing the service. One elderly woman narrated how she escorted her daughter to the hospital to access USS and was sent back home. She was told to go back after three days. The pregnant woman was demoralised and never went back:
“…Pregnant women suffer just to get a scan is a problem because they have to spend the whole day in long ques and sometimes they spend whole week without accessing a scan because the nurses keep rescheduling the appointment. The hospital is big to serve everyone. There must be at least a scanner just for pregnant women… [58 years woman, FGD women Kanyama]
3.4.2.1.2. Untrained Midwives to conduct, read and interpret USS
During ANC visits, Midwives used fetalscope to determine the heartbeat and position of the fetus. The pregnant women felt uncomfortable with the process and questioned the accuracy of the instrument. Some Midwives would not explain the outcomes of the assessment yet the pregnant women would be sent to the radiography department to get an US. When an USS is taken at the radiology department, pregnant women would take the file back to the MCH department for further assessments and interpretations. Majority of the Midwives did not know how to read and interpret the scans causing confusion and desperation for most pregnant women. One pregnant woman narrated how she panicked to the point of feeling as if she was about to die after undergoing scanning. She lamented that the two nurses attending to her during ANC were mumbling with each other without engaging her. Apparently the nurses failed to interpret the findings of the scan and opted to rather give her unclear explanations about the well-being of the baby which confused her even more. The nurses told her that the scan did not reveal the sex of the fetus and that subsequent scans were needed as the baby did not look healthy. They did not explain when and how the subsequent scans could be taken yet the women was allowed to go back home:
“I went for a scan. They did not tell me how the baby was in the womb, they just communicated to each other that this baby is showing patches of blood and for me, I just took it that the baby is showing blood… That is how I went outside… I sat down and started thinking…then I stopped a strange woman and I told her that I can read but I cannot understand this scan… then I went back into the scanning room and told them that I don’t understand anything and then the nurses started yelling at me saying what do you want us to do? We have a lot of people to attend to. I just went outside in anger … so, in such a situation if you are scared you can end up killing yourself…I just wanted to die” [FGD Chilenje women]
3.4.2.1.3. Insufficient space for USS within healthcare facilities
Participants expressed their concern over the inadequate physical space in all healthcare facilities to accommodate ultrasound services. They complained that the radiology department was always crowded as illustrated by long queues of clients waiting for various scanning services. They explained that long queues are a deterrent to pregnant women accessing scanning services. Most participants suggested that a separate room be created in existing structures or temporal structures be erected to accommodate pregnant women and their various USS needs:
“…We encounter a challenge because where scans are done, there is no space! Worse off in the radiology departments it is ever congested by everyone else and pregnant women are not a priority … So please consider partitioned rooms or create temporal structures for USS for pregnant women… [FGD Men Matero]
3.4.2.1.4. High cost of Scans and inadequate materials
Healthcare facilities lacked the necessary ultrasound materials and supplies as a result, participants were expected to incur ultrasound scanning cost and for materials and supplies. The minimum cost of a single ultrasound scan in government health facilities at the time of the study was K50 [$3] and K150 [$9] in privately owned healthcare facilities. Additionally, pregnant women were required to purchase and bring their own disposable wipes, water to drink, and pay towards the gel used in the performance of the USS. Pregnant women complained that they could not afford to pay for USS nor other materials. Those who could not afford to pay for the scans and purchase the supplies felt uneasy and demoralised to go for antenatal care. (Look for a quote)
3.4.2.1.5. Language barrier when reading the scans
The participants also complained of language barriers in interpreting the scan. Some nurses had difficulties explaining the outcome of the scans in simple terms that the clients would easily understand. Participants who do not understand English struggled to understand medical advice and were not able to communicate their needs effectively in English. Using local language may help patients to better understand their medical needs and improve the quality of healthcare they seek.
“…Some people are not good at English… what I have noticed is the problem with English. There are people who are not literate…the doctors and nurses explain most of the things in English. If one does not understand English, they leave without knowing anything…this language barrier is real and frustrating…we need people to explain to us in Nyanja the local language so that we understand. Or they should ask what language we are familiar with So that they can explain to you. The first thing we get asked when we get home is, what did they tell you at the hospital?...and because we did not understand, we end up keeping quiet... [FDG women Chilenje]
3.4.2.1.6. Long ques for the scans and transport costs
Participants complained that most radiology departments were crowded and that pregnant women were not prioritised to access the service. Instances of pregnant women missing their scheduled scanning appointments were numerous leading to clients simply shunning away from this valuable service. Long ques were compounded by transport cost barrier. To address this issue, participants recommended that there be a fixed schedule and a personnel specifically assigned to conducting scans for pregnant women. This is what one of the participant had to say:
“When USS is introduced, there must be a person chosen to be responsible for taking care of the machine and that person must be available always whenever scans are needed for women for every pregnant woman …”[FGD men Mumbwa]
3.4.2.1.7. Clients being attended to by trainees
A few participants expressed their displeasure after discovering that their attendants were trainees who never sought their consent. They further complained that student nurses spent too much time palpating the abdomen. The trainees demonstrated poor procedure execution skills, inflicting pain as a result of aggressive palpations. Two participants narrated:
“Well. I … was not happy because they made me lie down on the bed for about almost 30 minutes. I was just there; I don't know if the person was not really sure of what she was doing. I don't know. There were 2 of them. This one came and checked and also told the friend to check and at the end of the day I started feeling stomach pains so I had to tell them that if they don't know what they are doing they should just leave me alone…” [FGD 1 women UTH].
“… I went to the University teaching hospital,…they were all trainees, what happened was that, this one comes and touches you and everyone else! They were all practicing on me. I was tired and started to feel very sick…I was frustrated although I did not confront them...” [FGD 5 women Chipata].
3.4.2.1.9. Bad attitude of nurses towards clients
Some participants reported that some women who attended ANC for the first time and had no clue as to what was expected of them. They received a harsh treatment referred to as “an attitude” from the healthcare workers, especially from the nurses. This hostile behaviour on the part of the healthcare workers constitutes an impediment towards achieving quality antenatal care services, including USS. One male participant who accompanied his wife to undertake USS at the radiology department described how his wife had a horrible experience following a run-in with a nurse who apparently was in a bad mood on that day. The nurse appeared to be irritated with most of the pregnant women awaiting scanning services. The pregnant women identified the “attitude of nurses” as a turnoff and a source of anxiety they complained and swore never to go back for any scanning. He spoke:
“My wife came back upset from the clinic…the nurses did not treat her well. They were telling her to move out, go drink water back and forth…she got tired and her back was really hurting… even when they were palpating, they were shouting at her telling her to sleep like this! or you do not know why you have come here? it was traumatizing for her…” [FGD mixed group Chilenje].
The participants complained that the nurses do not interact with the clients while they are providing scanning services. Usually they do not explain the process and are constantly chit-chatting. One woman complained bitterly:
“… I did a scan and it was just nurses who were doing it … they were not talking to me; they were talking to each other. Imagine they are talking over you and not telling you what is going on. Most people go through it and they do not understand what is happening because even when you take the antenatal form today to the nurse after they have done the scan, they will not explain anything to you. It would be best for a doctor or someone who is more learned in this subject to actually be inside the room when these scans are done” [FGD for women Matero]
Some participants also explained that they were not free to ask questions to the nurses during the USS session because of fear of being rudely responded to. Same participant revealed:
“…Nurses will answer you so rudely that you get so scared to ask another question and you end up leaving” [FDG 1 LMUTH women]
3.4.2.1.9. Unclear procedural instructions for scanning
Healthcare facilities lack adequate man power therefore, to meet the high demand of antenatal care services, antenatal clinics are held early in the morning daily between 7am and 10am. These operational procedures by healthcare facilities are not conveyed to clients and have resulted in confusion. Most clients, particularly pregnant women, believe that nurses avoid their obligations and refuse to see them after 10 a.m. In one case, a pregnant woman went to ANC before 10 a.m. and was urged by a nurse to buy and eat something before being scanned since she had low blood pressure. When she returned a few minutes after 10 a.m., another nurse thought she had just arrived. Without asking her why she arrived at that specific time, the nurse informed the pregnant woman that she could not attend to her, outside of operational hours. Despite having low blood pressure and full of disappointment, the pregnant woman was forced to leave. A participant narrated:
“… I personally witnessed an incident of a pregnant woman who attended the clinic quite early in the morning and was advised to buy some food as her blood pressure was noted to be low. As she reported back around 10am, she found another nurse who thought she has just arrived. Without asking, she started shouting at the pregnant woman and refused to attend to her. The poor lady had no choice but to leave despite the fact that her BP was not OK… [ FGD2/Chilenje women]
Both male and female participants complained that nurses in the radiology department, who serve as the point of contact at every level of care in healthcare facilities, would not adequately explain the stages involved in the scanning process. For example, all pregnant women are supposed to drink water prior to scanning to make the bladder full which act as an acoustic window. Some participants narrated their stories of how they were harshly ordered to drink water prior to being scanned since details of the procedure were not clearly explained:
“As for me, things were not good at all…the moment my wife presented herself at the records with her form indicating that she needed to have a scan done on her, the attending nurse rudely shouted that she is supposed to go and drink water. I asked her, how was she supposed to guess that she has to drink water because she was not told about it? And then she retorted: if you are not serious, move away so that we attend to the next person… “[FGD for Men Chilenje]
3.4.2.1.10. Insensitivity of nurses to understanding the clients’ reasons for USS
One participant bemoaned the insensitive attitude of the nurses about respecting clients’ wishes and reasons for undergoing scanning. She lamented that nurses made the disclosure of the baby’s sex a priority and yet she was more concerned about the wellbeing of the fetus. She suggested that nurses engage clients prior to scanning in order to explain the procedure first and inquire about clients’ expectations in return and finally take time to explain the findings. She expressed herself furiously:
“…I was not happy when they told me the sex of my child… I did not go there to check the sex of my child. Instead, I went there to check if my baby was fine and to know the delivery date but upon receiving the scan information they hurriedly told me that my baby is fine and that it is a boy… I did not want to know the sex! Afterwards, I was depressed because I wanted a girl child! So these healthcare workers they should be asking if you want to know the sex or not” [FGD 1 women Matero]
3.5. Perceived facilitators to acceptability of the ultrasound scanning intervention in the healthcare facilities
The participants were informed about the need to introduce ultrasound scanning services in the participating healthcare facilities, specifically in the MCH departments, as one way of reducing preterm birth and stillbirths. It was further explained to them that this intervention would attract no cost at all on their part and would be offered to all pregnant women in the first trimester of gestational ages of 12 to 24 weeks.Participants were then requested to discuss and give their opinions on suggested facilitators to feasibility and acceptability by reflecting on the advantages of having the USS service available for the entire community. The following were proposed as facilitators: 1) Increased awareness about USS by clients and community members; 2) USS for increasing male participation and a paternity conflict resolution technique; 3) USS for psychological and financial preparedness; 4) Free USS a money serving technique; 5) USS by midwives for reducing time spent in queues and staff burnout
3.5.1. Increased awareness about USS by clients and community members
All participants across the 11 study sites enthusiastically agreed that introducing the USS “is the best idea ever!” They said that bringing the USS to MCH department will increase awareness and encourage pregnant to access the services. They further acknowledged that most pregnant women in the communities do not get scanned until they give birth which poses a risk to the mother’s health as well as that of her unborn child. One of the participants said:
“... A good number of women go on with their pregnancy up until around 8 months with no check-up at all! They would never take any medicine or speak to anyone about what they are going through… introducing and explaining the advantage of the scanning services to the community will definitely encourage mothers to attend the antenatal care early in their pregnancy and benefit from this intervention for them to know what is going on with the baby inside…” [FGD women Chilenje]
3.5.2. USS for increasing male participation and a paternity conflict resolution technique
Male participants appeared happier when they heard about the USS being made available in MCH department. They stated that men are seldom involved in antenatal care. They believe that the advent of USS would somehow motivate them to escort their wives during antenatal clinic as this intervention gives a tangible idea of the welfare of the unborn child. They further asserted that USS would help resolve uncertainties regarding paternity in some cases as it gives an idea on the gestational age because oftentimes, they argue, men are simply informed by their partners about the pregnancy without further details about its duration. One of the male participants related how the USS helped him clarify and settle a paternity dispute with his wife. The participant falsely accused his wife of trying to terminate the pregnancy because he thought she was having an affair. He felt relieved that there had been no attempt to terminate the pregnancy and that the scan had revealed the correct gestational age.
“My wife went for a scan and what caused us to go for a scan was that she had complications during her pregnancy… She used to complain about her stomach…she was referred to UTH from the local clinic with the note reading ‘attempted abortion’…and it made me think of doing a scan because it made me think that maybe my partner wanted to abort because the child might not have been mine even though there were no signs of bleeding or anything. That is why I had to rush her for a scan to see how the baby was growing and I was reassured that it was all ok…”. [FGD Kanyama men]
3.9.3. USS for psychological and financial preparedness
All participants, both female and male agreed that the USS within their local healthcare facility will help expectant couples make informed financial preparations as they look forward to the coming of the new born. Some male participants suggested that USS are very much welcome in that, they would certainly help dispel any concerns about fake pregnancies and confirm any genuine ailment the spouse might be affected with, such as fibroids and spare them from any psychological shock besides confirming the baby’s sex. One male participant had this to say: described his experience, in which he believed his partner to have fibroids. He bought clothes for the wrong sex of the unborn child after learning that she was pregnant because she had not had a scan:
“From my own point of view, I think scanning is very good and most of us living in rural areas we need to know about it. In my case, I doubted that my wife was pregnant because I thought she had fibroids and yet she was indeed expecting. The day she gave birth to a baby girl, I showed up with clothes for a baby boy. It would have saved me from buying the wrong clothes had I known the baby’s sex. So, it would really help if these scans are brought to the local clinic….” [FGD men Chongwe]
3.9.4. Free USS a money serving technique
When informed that USS will be free for expectant women with a gestational age of 12 to 24 weeks, the female participants expressed their excitement and remarked that many women in the communities will be able to participate because, in most cases, they do not have money to pay for the scans. Pregnant women still have other priorities, such as buying food for their households and clothing for their unborn children, even when they have money. Pregnant women frequently decide against spending money on the scan and instead choose to buy food to satisfy their cravings. One lady stated:
“Our husbands are casual workers so for them to give you money for a scan it is a struggle. Most of the time when you are given the money you have to make a choice whether to pay for the scan or buy ice cream so you end up buying food for your craving and also other things like clothes for yourself and the baby…” [FDG women Chongwe]
3.9.6. USS by midwives for reducing time spent in queues and staff burnout
Most healthcare facilities serve large catchment areas and have one radiology department which, besides USS services, carries out other imaging investigations by few overworked and stressed-out technicians. Provision of USS Services by midwives in MCH departments would bring a great relief to the local communities and especially to pregnant women and Radiology technicians in healthcare facilities:
“The staff do their work but they serve lots of people and use only one scanning machine. Machines in MCH will separate staff scanning those who come for general ailments and those that are pregnant and staff will be happy to work also there will not be frustrations for us because we will not spend all day in the queue…”[FGD women Matero]
“…There is congestion at the radiography department… because there is only one machine …Most women complain because staff are overworked. Even if the staff is very hard working, looking at the number of people that they serve, there are too many …people complain of being in ques for long hours and the whole day… Normally when you are in pain you tend to think people are not working… If we had at least 2 or 3 scanning machines in MCH we would appreciate it because, it would be quick and there will be division of labour… [FGD men Mumbwa]