The Patient Experience Across Antenatal Care Wellness Exams
Wellness exams to assess the well-being of mother and fetus are a key part of care for pregnant women. In LMICs, this is typically an abdominal exam performed by palpation. Especially when there are only a limited number of wellness exams over the course of a woman’s pregnancy, accurate assessment is crucial. Ultrasound imaging can yield much more accurate and comprehensive information safely and with less time and effort. It is not routinely available, however, for antenatal care in LMICs. Innovation is needed to increase access to antenatal ultrasound screening by making it more affordable and less dependent on specialized training.
WHO Guidelines
The WHO recommends one ultrasound scan before 24 weeks of gestation, without specifying at what level of the health system it should be performed.
Screening
Pregnant women seeking antenatal care often start at a local PHC facility. Health workers there, such as a midwife or nurse, perform an abdominal exam to assess the well-being of the mother and the fetus. This exam commonly lasts 30-45 minutes. Women may return for additional exams over the course of their pregnancy, but the accuracy of the initial assessment is especially important. These exams include assessment of multiple fetal aspects, typically by palpation: fetal number, orientation, movement, and size (using as a proxy fundal height, which is the distance from the top of the uterus to the pubic bone). Fundal height is commonly measured as finger widths or with a tape measure if available, and it is used to estimate gestational age, with 1 cm corresponding to approximately 1 week of gestation. Fetal heart rate is assessed using a fetoscope (a fetal stethoscope).The obstetric exam identifies pregnancy risks and complications. They include the presence of more than one fetus, a breech orientation of the fetus, discrepancy between the gestational age estimated by fundal height and by last menstrual period (that could indicate intrauterine growth restriction), and abnormal frequency of fetal movement. In these cases, women are referred for further evaluation that includes ultrasound imaging if available. Some PHC facilities have handheld Doppler ultrasound equipment used for a limited assessment: confirming fetal cardiac activity and viability. Most, however, do not have the equipment or trained personnel to perform the comprehensive antenatal ultrasound imaging recommended by the WHO. This results in patients being referred from the PHC facility to higher-level facilities.
Challenges
Obstetric exams performed by palpation and with simple tools, such as a tape measure and a fetoscope, are much less accurate than ultrasound imaging. They can yield inaccurate gestational age estimates, for instance, due to variability in the health worker’s hand and finger size and their level of expertise. This can result in lost opportunities to prevent the consequences of preterm birth or in unnecessary induction of labor for a misdiagnosed post-term pregnancy. They can also miss detecting other types of high-risk pregnancies, and they are labor-intensive and time-consuming, taxing the capacity of PHC facilities.
Obstetric ultrasound is an accurate and efficient alternative, but it is not commonly available at the PHC level where pregnant women first seek care. This requires referral to higher-level facilities, causing delays and lost opportunities for timely care. The main challenges to increasing access to ultrasound technology at the PHC level are the lack of affordable devices and a shortage of trained personnel to perform the scans and interpret the results.
Lack of Access to Ultrasound Imaging is a Critical Gap in Antenatal Care
Ultrasound imaging over the course of pregnancy can efficiently provide accurate and comprehensive information on the well-being of mother and fetus. This information improves diagnosis of pregnancy risks and complications and improves their management. Technology innovation is needed to make a point-of-care ultrasound (POCUS) tool that is more affordable and less dependent on specialized skills, so it can be a core part of antenatal care in LMICs.