Performance of late pregnancy biometry for gestational age dating in low-income and middle-income countries: a prospective, multicountry, population-based cohort study from the WHO Alliance for Maternal and Newborn Health Improvement (AMANHI) Study Group

Deb, Saikat; Mohammed, Mohammad Said; Dhingra, Usha; Dutta, Arup; Ali, Syed Mohammed; Dixit, Pratibha; Juma, Mohammed Hamad; Hassan, Massoud Juma; Sazawal, Sunil; Nisar, Imran; Ilyas, Muhammad; Mehmood, Usma; Kausar, Farzana; Jaweed, Shamim; Karim, Muhammad; Hussain, Atiya; Nadeem, Naila; Jehan, Fyezah; Rahman, Sayedur; Islam, Nazar Ul; Azad, Ruksana; Moin, Syed Mamum Ibne; Rahman, Mahdia; Ahmed, Salahuddin; Quiayum, Abdul; Khanam, Rasheda; Baqui, Abdullah H; Yoshida, Sachido; Manu, Alexander; Bahl, Rajiv; Lee, Anne C C; Naqvi, Mariam; Schaeffer, Lauren E.; Whelan, Rachel; Wylie, Blair J.

doi:10.1016/s2214-109x(20)30034-6

Cited by 27 publications

(14 citation statements)

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“…Compared with the conventional, more complex circumferential measurements of abdominal circumference (AC) and head circumference (HC), measurement of the FL requires only an image of a straight bone, making it a much easier measurement to obtain ( 6 , 32 ). The reported difference in the gestational age assigned by FL alone is only ±2.4 days at <24 + 0 weeks, ±1.7 days at 24–29 + 6 days and ±1.8 days at >30 + 0 weeks ( 33 ). We believe that utilizing this approach has the potential to maximize the sustainability and implementation of this US training program without compromising clinical care.…”

Section: Discussionmentioning

confidence: 99%

“…There is a lack of consensus on the assessment of competency in obstetric ultrasound and a number of previous programs have omitted practical assessment completely ( 27 , 31 , 35 , 38 – 40 ). The OSCE approach to “hands-on” assessment is well-established ( 24 , 26 , 28 , 30 , 41 ), as is the concept of comparing trainee measurements with those obtained by the faculty ( 20 , 22 , 23 , 33 , 42 ). By combining these, we sought to ensure that all aspects of our curriculum were assessed, with trainees demonstrating their ability to explain and document their findings as well as obtain accurate results.…”

Section: Discussionmentioning

confidence: 99%

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Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi

Viner

Membe‐Gadama

Whyte

et al. 2022

Front. Glob. Womens Health

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IntroductionAlthough ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organisation, it remains unavailable to many women in low-income countries where trained practitioners are scarce. This study aimed to evaluate a novel, context-specific education package to teach midwives basic obstetric ultrasound, including the determination of gestational age by measurement of fetal femur length.MethodsThe study was conducted across six sites in Malawi in January 2021. Following a virtual “training of the trainers”, local teams delivered a 10-day programme encompassing both didactic and “hands on” components. Matched pre and post course tests assessed participants' knowledge of key concepts, with Objective Structured Clinical Examinations used to evaluate practical skills. To achieve a pass, trainees were required to establish the gestational age to within ±7 days of an experienced practitioner and achieve an overall score of >65% on five consecutive occasions. A matched pre and post course survey explored participants' attitudes and confidence in performing ultrasound examinations.ResultsOf the 29 midwives who participated, 28 finished the programme and met the criteria specified to pass. 22 midwives completed the matched knowledge tests, with the mean (SD) score increasing from 10.2 (3.3) to 18 (2.5) after training (P <0.0001). Mean difference 7.9, 95% CI 6.5–9.2. Midwives passed 87% of the Observed Structured Clinical Examinations, establishing the gestational age to within ±7 days of an experienced practitioner in 89% of assessments. Beliefs regarding the importance of antenatal ultrasound increased post course (p = 0.02), as did confidence in performing ultrasound examinations (p <0.0001).ConclusionThis study demonstrates not only that ultrasound-naive practitioners can be taught to perform basic obstetric ultrasound dating scans, confidently and competently, after 10 days of training, but also that local teams can be orientated to successfully deliver the programme virtually. Previous ultrasound training initiatives, while often more comprehensive in their syllabus, have been of considerably longer duration and this is likely to be a barrier to upscaling opportunities. We propose that this focused training increases the potential for widescale and sustainable implementation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi

Viner

Membe‐Gadama

Whyte

et al. 2022

Front. Glob. Womens Health

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“…This holistic approach may account for the increased accuracy later in the pregnancy, when the correlation between GA and physical size of the fetus is less pronounced. This may be especially helpful in providing more accurate estimated GA in LMIC settings where access to ultrasound in early pregnancy is rare 30 .…”

Section: Discussionmentioning

confidence: 99%

A mobile-optimized artificial intelligence system for gestational age and fetal malpresentation assessment

et al. 2022

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Background Fetal ultrasound is an important component of antenatal care, but shortage of adequately trained healthcare workers has limited its adoption in low-to-middle-income countries. This study investigated the use of artificial intelligence for fetal ultrasound in under-resourced settings. Methods Blind sweep ultrasounds, consisting of six freehand ultrasound sweeps, were collected by sonographers in the USA and Zambia, and novice operators in Zambia. We developed artificial intelligence (AI) models that used blind sweeps to predict gestational age (GA) and fetal malpresentation. AI GA estimates and standard fetal biometry estimates were compared to a previously established ground truth, and evaluated for difference in absolute error. Fetal malpresentation (non-cephalic vs cephalic) was compared to sonographer assessment. On-device AI model run-times were benchmarked on Android mobile phones. Results Here we show that GA estimation accuracy of the AI model is non-inferior to standard fetal biometry estimates (error difference −1.4 ± 4.5 days, 95% CI −1.8, −0.9, n = 406). Non-inferiority is maintained when blind sweeps are acquired by novice operators performing only two of six sweep motion types. Fetal malpresentation AUC-ROC is 0.977 (95% CI, 0.949, 1.00, n = 613), sonographers and novices have similar AUC-ROC. Software run-times on mobile phones for both diagnostic models are less than 3 s after completion of a sweep. Conclusions The gestational age model is non-inferior to the clinical standard and the fetal malpresentation model has high AUC-ROCs across operators and devices. Our AI models are able to run on-device, without internet connectivity, and provide feedback scores to assist in upleveling the capabilities of lightly trained ultrasound operators in low resource settings.

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“…Recent evidence suggested that using US in second/third trimester with a novel parsimonious formula might narrow accuracy to ± 10.5 days (between 24 0/7 weeks and 29 6/7 weeks of gestation) and of ± 15.1 days (between 24 0/7 weeks and 29 6/7 weeks of gestation) [ 14 ]. These results suggest that concentrating efforts and resources in further validating and implementing the use of late pregnancy biometry for gestational age assessment may be valuable in settings where the preferred reference standards are unavailable.…”

Section: Discussionmentioning

confidence: 99%

Comparison of alternative gestational age assessment methods in a low resource setting: a retrospective study

Pietravalle

Spolverato²,

Brasili³

et al. 2022

BMC Pregnancy Childbirth

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Background Accurate gestational age (GA) determination allows correct management of high-risk, complicated or post-date pregnancies and prevention or anticipation of prematurity related complications. Ultrasound measurement in the first trimester is the gold standard for GA determination. In low- and middle-income countries elevated costs, lack of skills and poor maternal access to health service limit the availability of prenatal ultrasonography, making it necessary to use alternative methods. This study compared three methods of GA determination: Last Normal Menstrual Period recall (LNMP), New Ballard Score (NBS) and New Ballard Score corrected for Birth Weight (NBS + BW) with the locally available standard (Ultrasound measurement in the third trimester) in a low-resource setting (Tosamaganga Council Designated Hospital, Iringa, Tanzania). Methods All data were retrospectively collected from hospital charts. Comparisons were performed using Bland Altman method. Results The analysis included 70 mother-newborn pairs. Median gestational age was 38 weeks (IQR 37–39) according to US. The mean difference between LNMP vs. US was 2.1 weeks (95% agreement limits − 3.5 to 7.7 weeks); NBS vs. US was 0.2 weeks (95% agreement limits − 3.7 to 4.1 weeks); NBS + BW vs. US was 1.2 weeks (95% agreement limits − 1.8 to 4.2 weeks). Conclusions In our setting, NBS + BW was the least biased method for GA determination as compared with the locally available standard. However, wide agreement bands suggested low accuracy for all three alternative methods. New evidence in the use of second/third trimester ultrasound suggests concentrating efforts and resources in further validating and implementing the use of late pregnancy biometry for gestational age dating in low and middle-income countries.

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Performance of late pregnancy biometry for gestational age dating in low-income and middle-income countries: a prospective, multicountry, population-based cohort study from the WHO Alliance for Maternal and Newborn Health Improvement (AMANHI) Study Group

Cited by 27 publications

References 20 publications

Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi

Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi

A mobile-optimized artificial intelligence system for gestational age and fetal malpresentation assessment

Comparison of alternative gestational age assessment methods in a low resource setting: a retrospective study

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