Use and misuse of ultrasound in obstetrics with reference to developing countries

Asim Kurjak; Edin Medjedovic; Milan Stanojević

doi:10.1515/jpm-2022-0438

Article Publicly Available

Use and misuse of ultrasound in obstetrics with reference to developing countries

Asim Kurjak , Edin Medjedovic and Milan Stanojević

Published/Copyright: October 28, 2022

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From the journal Journal of Perinatal Medicine Volume 51 Issue 2

Abstract

Maternal and neonatal health is one of the main global health challenges. Every day, approximately 800 women and 7,000 newborns die due to complications during pregnancy, delivery, and neonatal period. The leading causes of maternal death in sub-Saharan Africa are obstetric hemorrhage (28.8%), hypertensive disorders in pregnancy (22.1%), non-obstetric complications (18.8%), and pregnancy-related infections (11.5%). Diagnostic ultrasound examinations can be used in a variety of specific circumstances during pregnancy. Because adverse outcomes may also arise in low-risk pregnancies, it is assumed that routine ultrasound in all pregnancies will enable earlier detection and improved management of pregnancy complications. The World Health Organization (WHO) estimated in 1997 that 50% of developing countries had no access to ultrasound imaging, and available equipment was outdated or broken. Unfortunately, besides all the exceptional benefits of ultrasound in obstetrics, its inappropriate use and abuse are reported. Using ultrasound to view, take a picture, or determine the sex of a fetus without a medical indication can be considered ethically unjustifiable. Ultrasound assessment when indicated should be every woman’s right in the new era. However, it is still only a privilege in some parts of the world. Investment in both equipment and human resources has been clearly shown to be cost-effective and should be an obligatory step in the improvement of health care. Well-developed health systems should guide developing countries, creating principles for the organization of the health system with an accent on the correct, legal, and ethical use of diagnostic ultrasound in pregnancy to avoid its misuse. The aim of the article is to present the importance of correct and appropriate use of ultrasound in obstetrics and gynecology with reference to developing countries.

Keywords: gynecology; maternal health; obstetrics

Introduction

The history of sonography in obstetrics and gynaecology started with the classic 1958 Lancet paper of Ian Donald and his team from Glasgow [1]. Today, practicing obstetrics and gynecology without ultrasound is unimaginable. Ultrasound is convenient examination and safe even for the embryo [2]. However, the usefulness of ultrasound depends heavily on the operator’s skill. Real-time imaging, color and power Doppler, transvaginal sonography, and 3/4D imaging have been used for the assessment of fetal growth and wellbeing, screening for fetal anomalies, prediction of preeclampsia and preterm birth, and detection of ectopic gestation, evaluation of pelvic masses, screening for ovarian cancer and fertility management [1]. Ultrasound poses a significant role in reducing mortality and morbidity in mothers and their babies [3]. The aim of the article is to present the importance of correct and appropriate use of ultrasound in obstetrics and gynecology with reference to developing countries.

Maternal and neonatal mortality and morbidity

Lee Jong-wook, former director of the World Health Organization (WHO), once said: “Even in the 21st century, we still allow well over 10 million children and half a million mothers to die each year, although most of these deaths can be avoided [4].”

In 2017, 295,000 maternal deaths occurred and the global maternal mortality rate (MMR) was 211 maternal deaths per 100,000 live births [7]. Sub-Saharan Africa alone accounted for 66%, and Southern Asia for 20% of global maternal deaths [7]. With approximately 67,000 and 35,000 maternal deaths, Nigeria and India accounted for 23 and 12% of global maternal deaths, respectively [7]. The lifetime risk of maternal death in sub-Saharan Africa is 1 in 37, while in Australia and New Zealand is just 1 in 7,800 [7]. MMR in the world’s least developed countries (415 per 100,000 live births) is more than 40 times higher than MMR in Europe [10], and almost 60 times higher than in Australia and New Zealand [7]. South Sudan, Chad, and Sierra Leone are estimated to have had extremely high MMR in 2017 (over 1,000 maternal deaths per 100,000 live births) [7].

Almost 75% of all maternal deaths are caused by severe bleeding, infections, high blood pressure during pregnancy, complications from delivery, and unsafe abortion [6]. The leading causes of maternal death in sub-Saharan Africa are obstetric hemorrhage (28.8%), hypertensive disorders in pregnancy (22.1%), non-obstetric complications (18.8%), and pregnancy-related infections (11.5%) [8].

The estimated number of neonatal deaths was 2.5 million deaths in 2017 [9].Together, South Asia and sub-Saharan Africa accounted for 79% of the total neonatal deaths [9].Neonatal mortality rate (NMR, number of neonatal deaths per 1,000 live births) was more than 9 times higher in west and central Africa (30.2 per 1,000 live births) and south Asia (26.9 per 1,000 live births) than in high-income countries (3.0 per 1,000 live births) [9]. Leading causes of neonatal deaths in 2017 were: complications associated with preterm birth (35%), birth asphyxia (24%), sepsis and meningitis (14%), and congenital anomalies (11%) [9]. In sub-Saharan Africa, leading causes of nonatal deaths are infections such as tetanus, sepsis and pneumonia, preterm birth complications, and birth asphyxia [10]. In a study conducted in western Ethiopia, 60% of neonatal deaths in the period 2010–2014 were due to infection [11].

It is clearly shown that maternal and neonatal mortality result from preventable causes [12]. It is estimated that 71% of neonatal and 51% of maternal deaths annually can be prevented through increased coverage of preconception, prenatal, intrapartum, and postnatal care [13]. Almost 3 million lives could be saved each year by high coverage of care around the time of birth, and care of small and sick newborns, at an additional cost of just 1.15 US$ per person [5]. In low-income countries, about 50% of mothers have no access to skilled attendants at birth, and over 70% of extra hospital deliveries do not receive postnatal care [13]. Studies conducted in Ethiopia, sub-Saharan Africa, and Iran showed that good prenatal care and skilled personnel at birth decrease the odds of neonatal death [14], [15], [16]. Even one antenatal care visit in pregnancy, by a skilled provider, reduces the risk of neonatal mortality by 39% in sub-Saharan African countries [10].

The ultrasound is proven to be reducing maternal and neonatal mortality and morbidity [17]. It is considered a type of sustainable technology for developing countries due to the relatively low cost of purchase, maintenance, and supplies, as much as due to its portability and durability in comparison with other imaging modalities [18]. Additionally, ultrasound is non-invasive, safe, readily available, and widely acceptable.

Ultrasound in obstetrics and gynecology

A typical gynecological sonographic examination includes the following components: uterine size, shape, and orientation; appearance of the endometrium, myometrium, and cervix; assessment of the uterus and adnexa for masses, cysts, hydrosalpinx, fluid collections, and mobility; and evaluation of the cul-de-sac for free fluid and masses [19]. Screening for ovarian cancer with the goal of detecting malignancy in an early stage is the greatest area of interest of ultrasound in gynecology but did not prove beneficial in a reduction of ovarian cancer mortality and had a high false-positive rate [20].

Diagnostic ultrasound examinations can be used in a variety of specific circumstances during pregnancy. Because adverse outcomes may also arise in low-risk pregnancies, it is assumed that routine ultrasound in all pregnancies will enable earlier detection and improved management of pregnancy complications. Potential life-threatening complications and severe health outcomes during the immediate postnatal period as a result of fetal malpresentation, multiple gestations, ectopic pregnancy, placenta accreta spectrum, and placenta praevia, may be identified earlier and appropriately managed with the use of an ultrasound screening study [21]. As a result of comprehensive health care services, ultrasound has become a routine part of obstetric care in the developed world.

Fetal ultrasound examinations are classified as [22]:

Standard first-trimester ultrasound assessment including evaluation of the presence, size, location, and number of gestational sacs with detection of a yolk sac and embryo/fetus;
Standard second- or third-trimester ultrasound assessment – including evaluation of the number of fetuses, cardiac activity, presentation, volume of amniotic fluid, position of the placenta, fetal biometry, and assessment of fetal anatomy, together with evaluation of maternal cervix and adnexa;
Limited ultrasound assessment – performed to answer a specific, acute clinical question when an immediate impact on management is anticipated and when a standard ultrasound assessment is impractical or unnecessary;
Specialized ultrasound assessment – a detailed examination of women at risk for fetal abnormalities or when fetal malformation is suspected; may include a fetal echocardiogram, biophysical profile, and fetal Doppler ultrasound or additional biometric measurements.

Routine ultrasound screening in pregnancy

The American College of Obstetricians and Gynecologists (ACOG) approved different screening modalities then previously mentioned [23]. For a single screening examination, 18–20 weeks of gestation is the optimal time for detection of fetal anomalies and assessment of the placenta and umbilical cord, confirmation of singleton/multiple gestation, and assessment of cervical length (CL), and fetal growth [23]. If two screening exams are performed, the first is typically done either at 7–10 weeks of gestation for a reliable assessment of pregnancy dating or, at 11–14 weeks for nuchal translucency examination, pregnancy dating, and early depiction of fetal anatomy. The second screening examination is performed at 18–20 weeks when fetal anatomy, growth, and pregnancy dating are evaluated [23].

International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) recommends the first ultrasound scan when gestational age is thought to be between 11 and 13 + 6 weeks gestation, as this provides an opportunity to detect gross fetal abnormalities and measure the nuchal translucency thickness [24]. In the absence of clinical concerns, pathological symptoms, or specific indications, routine ultrasound just to confirm an ongoing early pregnancy is unreasonable [24].

In its 2016 antenatal care recommendations, the World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce the induction of labor for post-term pregnancy, and improve a woman’s pregnancy experience [25]. Once women had an early US scan, a routine scan after 24 weeks is not recommended. If an early US scan is not performed, a scan later in pregnancy for identifying the number of fetuses, fetal presentation, and placental location can be considered [25].

First-trimester screening

The first-trimester ultrasound is recommended for accurate pregnancy dating (ideally at 7–12 weeks) [26]. Crown–rump length (CRL) is the most commonly used fetal measurement for this purpose [27]. Improved determination of gestational age in early pregnancy results in fewer inductions for post-maturity [28]. If performed between 11 and 14 week of gestation, ultrasound screening should include basic fetal anatomy [26]. About half of all major structural anomalies can be detected in the first trimester, including acrania/anencephaly, abdominal wall defects, holoprosencephaly, and cystic hygroma [29].

In multiple gestations, early ultrasound allows for reliable determination of chorionicity and amnionicity [26]. Compared with dichorionic, monochorionic twins are at increased risk for poor perinatal outcomes such as twin-to-twin transfusion syndrome, prematurity, fetal growth restriction, and intrauterine fetal death. Therefore, determination of chorionicity is of great importance in the management of multiple gestations [30].

The first trimester is an ideal time for screening for fetal aneuploidy and the nuchal translucency (NT) measurement is an excellent screening tool (Figure 1). The prevalence of chromosomal defects increases exponentially with increasing NT thickness [31]. The performance of the test can be improved even further by combining it with biochemical markers (free-beta human chorionic gonadotropin – hCG and pregnancy-associated plasma protein A – PAPP-A) and other sonographic markers such as the nasal bone (NB), tricuspidal-valve (TCV) or ductus venosus (DV) Doppler flow evaluation [31] (Figures 2 –4).

Figure 1:

Nuchal translucency (NT) in fetus with trisomy 21 at 11 weeks of gestation.

Figure 2:

Absent nasal bone (NB) in fetus with trisomy 21 at 12 weeks of gestation.

Figure 3:

Tricuspid valve (TCV) regurgitation assessed by Doppler ultrasound.

Figure 4:

Ductus venosus (DV) reverse flow shown by Doppler waves and color doppler.

Increased NT in fetuses with normal karyotype is associated with an increased risk of fetal structural anomalies, most commonly congenital heart defects (CHDs) [32].

Nuchal translucency above 3.5 mm indicates possibility of fetal heart defect or other malformations and should be the reason for more detailed assessment by maternal-fetal medicine specialist [33]. Increased nuchal translucency in the first trimester of unknown etiology is associated with a significantly increased risk of abortion, fetal growth restriction, preterm birth, low birth weight, and preeclampsia [34].

First-trimester ultrasound has been proved to be beneficial in the detection of abnormalities in early pregnancy [35]. The most common conditions in the first trimester which can cause maternal death are severe hemorrhage, shock, or sepsis, ectopic pregnancy, abortion, and gestational trophoblastic diseases (GTDs) [35]. Ultrasound imaging is extremely useful for obtaining an accurate diagnosis and can potentially reduce maternal mortality rates [35].

The leading cause of maternal deaths in the first trimester of pregnancy is ectopic pregnancy [36]. In African developing countries, case fatality rates are 1–3% which is 10 times higher than reported in industrialized countries [37] In Ghana and Cameroon 8.7 and 1.5% of maternal deaths were due to ectopic pregnancy, respectively [37]. Although not recommended to diagnose pregnancy, the first-trimester ultrasound is important in confirmation of intrauterine pregnancy [35]. When the uterus is empty, the adnexa should be thoroughly and systematically inspected [35]. The finding of an intrauterine pregnancy (IUP) almost always excludes the diagnosis of ectopic pregnancy (EP). However, the examiner must be aware of the possibility of heterotopic pregnancy especially if a woman has conceived using assisted reproductive technology [38]. When an obvious extrauterine embryo is absent, visualization of an empty uterus, adnexal mass, free fluid, or a pseudo sac has poor sensitivity but good specificity for the diagnosis of tubal pregnancy [39]. Almost 75% of all EP are identified by the initial transvaginal sonography, remaining 25% are classified as pregnancy of unknown location [40].

Transvaginal sonography (TVS) provides superior resolution and more accurate identification of the embryonic structures than abdominal ultrasound, especially in obese patients and ones with a retroverted uterus [41]. TVS enables in-vivo examination anatomy of early pregnancy, uteroplacental circulation, and intervillous circulation. It is considered the gold standard in the diagnosis and management of incomplete miscarriage [42]. A clinical diagnosis of miscarriage, based on clinical symptoms and vaginal examination, is inaccurate in more than 50% of cases when compared with ultrasound assessment [43]. Ultrasound diagnosis of miscarriage is made on well-defined parameters which include gestational sac, crown-rump length, secondary yolk sac, and fetal heart pulsation [43]. Additionally, to these parameters, trophoblast thickness, trophoblast volume and mean uterine artery pulsatility index are used in different combinations in order to predict miscarriage [44]. Combining ultrasound parameters with maternal serum markers such as human chorionic gonadotrophin, progesterone, PAPP-A, and high-sensitivity C-reactive protein, are used to determine the eligibility of expectant management of missed miscarriage [45]. Up to 70% of women will choose expectant management of miscarriage if given the choice [46]. This could significantly reduce the number of unnecessary evacuations of the retained products of conception [46].

Second-trimester screening

The second trimester ultrasound assessment is performed between 18 and 22 weeks of gestation which is the best time for a fetal depiction of fetal anatomy and detection of congenital malformations if present [47]. Ultrasound screening includes evaluation of the number of fetuses, gestational age, anatomy of the fetus, placenta, maternal uterus, cervix, and adnexa [47].

Ultrasound assessment of gestational age is very accurate in the second trimester [48]. After 14 weeks or once the CRL exceeds 84 mm, head circumference (HC) should be used for pregnancy dating [48]. HC alone, or with femur length (FL) can be used for the estimation of gestational age from the mid-trimester if a first-trimester scan is not available or the history of last menstrual period is unreliable [49].

Second-trimester anatomy assessment is recommended as the standard investigation for the detection of fetal structural anomalies which are found in up to 3% of all pregnancies [29] (Figures 5 –8). Congenital heart defects (CHD) are the most common congenital malformations and causes major morbidity and mortality [29]. Prenatal detection reduces morbidity and mortality by improving the neonatal condition before surgery [50].

Figure 5:

Atrial septal defect type secundum.

Figure 6:

Ventricular septal defect.

Figure 7:

Omphalocele.

Figure 8:

Occipital encephalocele.

Placental location, its relationship with the internal cervical os, and its appearance should be evaluated to exclude placenta previa [51]. If the lower placental edge reaches or overlaps the internal os, a follow-up examination in the third trimester is recommended [51].

A low-lying placenta sonographically diagnosed in the second trimester typically resolves by the mid-third trimester [52]. Only 9.8% of previas and low-lying placentas persist through delivery [53]. Women with a history of uterine surgery and low anterior placenta or placenta previa should be examined for findings of accreta, and if accreta is suspected, a more detailed evaluation is usually required to further investigate this possibility [51] (Figure 9).

Fetal biometry alone showed poor to moderate performance in prediction of small for gestational age (SGA) [54]. When combined with uterine artery Doppler, detection of term, preterm and very preterm SGA is 40, 66 and 89% respectively [54]. Uterine artery pulsatility index alone was able to predict 25, 60 and 77% of term, preterm and very preterm SGA at a 10% false-positive rate [54].

Routine Doppler ultrasound is not currently recommended as part of second-trimester screening in low risk or unselected pregnancies as it confer no benefit on mother or baby [55]. However, Doppler studies are important in prediction of high-risk pregnancies and their outcomes. Use of Doppler ultrasound on the umbilical artery in high‐risk pregnancies reduces the risk of perinatal deaths and may result in fewer obstetric interventions [56]. Elevated second-trimester uterine Doppler indices, as the indicator of impaired placentation, are more strongly associated with stillbirth than conventional risk factors [57]. Both uterine and umbilical artery Doppler are used for the prediction of preeclampsia and fetal growth restriction (FGR) to reduce the maternal and perinatal morbidity and mortality [58].

Preeclampsia is among the leading causes of maternal and fetal/neonatal mortality and morbidity with incidence of 2–7% of all pregnancies in developed countries and approximately 10% in developing countries [59]. Early identification of pregnant women at risk for preeclampsia is important to implement preventive measures and timely treatment. Some biochemical and ultrasonographic parameters have shown promising predictive value both in the first and second trimesters [60]. Uterine artery Doppler ultrasonography (Pulsatility Index) is better in predicting the occurrence of preeclampsia in the second trimester than in the first trimester [61]. The risk of severe preeclampsia was best predicted by second-trimester elevated resistance index [62]. The diastolic notch in uterine arteries in the second trimester of pregnancy is designated as an independent predictor of preeclampsia, especially when present bilaterally, with a positive and negative predictive value of 90.91 and 42.11%, respectively [63].

A short CL (≤25 mm) on transvaginal ultrasound between 16 and 24 weeks of gestation is associated with an increased risk for spontaneous preterm birth [64]. Besides being more cost-effective, a single CL measurement at 18–24 weeks of gestation showed to be a better predictor of preterm birth than changes in CL over time [65]. Moreover, the short cervix is more sensitive for predicting earlier forms of prematurity (at <32 weeks) than later forms of prematurity (>32 weeks) [66]. Prematurity has been the leading worldwide cause of neonatal mortality but also the leading cause of childhood mortality through the age of five years [67]. In 2005, 12.9 million births, or 9.6% of all births worldwide, were preterm [68]. Approximately 11 million (85%) of these preterm births were concentrated in Africa and Asia [68]. Routine transvaginal measurement of CL as a strategy for preventing premature birth is still controversial [69]. Large randomized controlled trials have failed to demonstrate proven efficacy for universal CL screening and cerclage placement in women with short CL because a large number of women need to be screened to prevent a relatively small number of preterm births [69]. On the other hand, limiting CL screening to women at risk results in missing nearly 40% of women with a short cervix [70]. Rates of early but not late spontaneous preterm birth are significantly higher among women who do not undergo CL screening [71]. In patients with a short cervix, treatment with vaginal progesterone or, in cases of previous preterm birth, cerclage have reduced the rate of subsequent preterm birth and composite perinatal mortality and mortality [72].

Third-trimester screening

Screening examinations in the third trimester are pregnancy-specific, its routine use in low pregnancies is not supported [73]. A routine ultrasound during the third trimester is used for the evaluation of fetal growth and presentation, amniotic fluid, and placental growth and location but also for a second evaluation of fetal morphology [74]. Incidental fetal anomaly is found in about 1 in 300 women scanned in the third trimester [75]. Third-trimester ultrasound is of great importance in the screening for late-onset preeclampsia, evaluation of uterine scar in a women with a previous cesarean section, prediction of labor, and management of fetal malpresentation and large for gestational age fetuses (LGA) [76]. LGA, i.e. macrosomic neonates (birth weight > 90th percentile) are at increased risk of perinatal death, birth injury due to traumatic delivery, and adverse neonatal outcomes [77, 78]. Two common ultrasound markers for macrosomic neonates at birth are estimated fetal weight (EFW) and abdominal circumference (AC) with a sensitivity of over 50% [78]. The predictive performance of routine third-trimester ultrasound for LGA is higher when the scan is performed at 36 than at 32 weeks [77]. Patients at high risk for fetal growth restriction often have two third-trimester screening examinations, one at 32 weeks and the other at 36 weeks [24]. Identification of fetuses at risk for FGR will allow timely management that can reduce perinatal morbidity and mortality [76]. Severe FGR is considered when absent end-diastolic flow is present in umbilical artery, as shown in the Figure 10.

Figure 9:

3D color Doppler assessment of placenta previa.

Figure 10:

Severe FGR with absent end-diastolic flow in the umbilical artery.

Ultrasound in developing countries

The World Health Organization (WHO) estimated in 1997 that 50% of developing countries had no access to ultrasound imaging, and available equipment was outdated or broken [79]. Portable ultrasound machines have become increasingly popular in LMICs (Low and Middle Income Countries) due to their affordability, simplicity, and effectiveness for patient management decisions in resource-poor settings [80, 81]. Small portable ultrasound device for use in LMICs is presented in the Figure 11.

According to Immelt, such pocket-sized technology like Vscan (Figure 11) has the potential to help redefine the physical exam and improve patient care by enhancing a doctor’s ability to quickly and accurately make a diagnosis [82].

Figure 11:

Smart phone-sized ultrasound system Vscan (GE Healthcare, Chicago, IL, United States).

A recent study identified the overall trend of increased training programs and ultrasound applications in LMICs over the past decade, primarily for obstetrical use and screening [81]. Studies in Cameroon and Liberia showed that 48 and 53% of ultrasound scans, respectively, were performed for either obstetric or gynecological conditions [83]. An antenatal ultrasound program as basic screening for high-risk pregnancies introduced in 2010 at a community health care center in rural Uganda resulted in a significant increase in the number of deliveries in a health facility and antenatal care visits [84].

The vast majority of all maternal and newborn deaths occur in developing countries [5], [6], [7]. As approximately 40% of fetal, neonatal, and maternal deaths occur during the peripartum period, early diagnosis of risk factors for intrapartum-related complications and subsequent referrals are the key strategic research priorities for developing countries [3]. In many developing countries, a baby born at 32 weeks of gestation (in the absence of intrauterine growth retardation) has little chance of survival, while the survival rate of infants born at 32 weeks in developed countries is similar to that of infants born at term [85]. An infant born at 32 weeks in a low-income country has only a 50% chance of survival [86].

There is evidence that obstetric uses of ultrasound improve patient management, but evidence of reducing maternal, perinatal, or neonatal mortality is opposing [87]. A study on 58 clusters across 5 LMICs (DRC, Kenya, Zambia, Gvatemala and Pakistan) compared usual care and intervention that included basic ultrasound at 16–22 and 32–36 weeks with referrals for US-diagnosed conditions [87]. There was no difference in intervention and comparison clusters in terms of antenatal care use, facility delivery, stillbirth rate, neonatal mortality, and maternal mortality despite US-naïve providers being successfully trained to conduct basic US exams [87]. Studies conducted in South Africa showed that routine second-trimester ultrasound scanning is not associated with substantive improvements in maternal or fetal outcomes [21].

Other trials proved that the use of ultrasound in obstetrics improves patient management in the developing world particularly through assessment of a number of gestations, fetal presentation, placental position, estimated due date and fetal growth [88]. In skilled hands, prenatal ultrasound showed the potential to reduce maternal, fetal, and neonatal mortality by improving the management of pregnancy complications and reducing birthing complications due to more deliveries in risk-appropriate settings [89]. With appropriate ultrasound machines, essential supplies, and capacitating mid-level providers, a significant number of high-risk pregnant women can be identified on time and managed or referred to health facilities with safe delivery services [90].

A study conducted in 25 health centers in Ethiopia estimated the contribution of obstetric ultrasound services to the prevention of maternal and neonatal morbidities and mortalities [90]. The investigators considered all possible risks for maternal and neonatal morbidities and mortalities which can be reduced through confirmation using advanced perinatal health services accessed through referral linkage [90]. The ultrasound service has contributed to the prevention of 1,970 maternal and 19.05 neonatal morbidities and mortalities per 100,000 and 1,000 live births respectively during the assessed two-year period [90].

Education

The education of health personnel is an important factor in obstetric ultrasound services’ quality implementation. An ultrasound machine alone won’t achieve benefits without properly trained health workers. A review article, that documented training opportunities for ultrasonography in LMICs, showed that most ultrasound scans are performed by general practitioners, obstetric physicians, and even non-medical personnel with little to no formal training in ultrasonography [91]. Additionally, ultrasonographic training in LMICs often does not meet the WHO criteria such as the number of scans under the supervision and the length of the training program [91].

With adequate training materials and methods, short intensive training courses provide substantial acquisition of knowledge and practical skills [83]. One study showed that after a 2-week course in basic obstetrics ultrasound and a 12-week period of oversight, trainees with no prior ultrasound experience performed basic OB ultrasound examinations independently to screen for high-risk pregnancies and achieved a 99.4% concordance in ultrasound diagnosis with reviewers [92].

Misuse of ultrasound

Unfortunately, besides all the exceptional benefits of ultrasound in obstetrics, its inappropriate use and abuse are reported. Obstetric ultrasound practice is ethically justifiable only if the indication for its use is based on medical evidence [93]. Using ultrasound to view, take a picture, or determine the sex of a fetus without a medical indication can be considered ethically unjustifiable [93].

A study in Botswana reported unindicated overuse of ultrasound by health professionals and neglect regarding conventional methods such as physical examinations and taking histories because of easy access to ultrasound [83]. A study conducted in Uganda reported overuse of ultrasound which was not associated with any identifiable effect on obstetric outcomes [94].

Financial motivations in providing unnecessary ultrasound services have been reported as way of misuse in LMICs [83]. After the initial ultrasound scan, multiple follow-up scans are often scheduled in private clinics to increase revenue [83]. Using ultrasound for financial gain or any not clinically-based reason significantly reduces the cost-effectiveness of services [83].

In some parts of the world, most notably in Asia, existing cultural biases have led to the inappropriate use of ultrasound scanners in sex selection by abortion if the baby is not of the desired gender [95]. In China, where son preference is aggravated by the historical One-Child Policy, and in India, where female infanticide is replaced by sex-selective termination of pregnancy (TOP), prenatal sex determination is banned [95]. Still, it remains a widespread practice and sex-selective TOP have a number of negative demographic effects [96]. In one study in Nepal, approximately 7% of women sought an ultrasound examination for fetal sex determination, predominantly ones with three or more live-born daughters and no live-born sons, which could indicate the intention of sex-selective abortion [97]. Ghanaian study about women’s experience and perception of ultrasound in antenatal care documented knowing fetal sex as a major motivation for which women go for antenatal scans [98]. However, fetal sex was accurately determined in only 86.5% of the cases [98]. Incorrect assessment of the fetal sex is not uncommon and can result in negative experiences for women, especially in cases when female fetuses are mistaken as male [83]. Accurate determination of fetal sex by ultrasound is shown in the Figure 12.

Figure 12:

Female (left) and male (right) gender at 12/13 weeks of gestation.

Conclusions

There is clear evidence of the importance of ultrasound in preserving feto-maternal health. The use of ultrasound in diagnostics is essential for the patients, the doctors, the healthcare system and for the entire society. Ultrasound assessment when indicated should be every woman’s right in the new era. However, it is still only a privilege in some parts of the world. Investment in both equipment and human resources has been clearly shown to be cost-effective and should be an obligatory step in the improvement of health care. Well-developed health systems should guide developing countries, creating principles for the organization of the health system with an accent on the correct, legal, and ethical use of diagnostic ultrasound in pregnancy to avoid its misuse.

Corresponding author: Edin Medjedovic, MD, PhD, Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina; and Department of Gynecology, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina, E-mail: medjedovic.e@gmail.com

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Not applicable.
Ethical approval: Not applicable.

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Received: 2022-09-07

Accepted: 2022-10-04

Published Online: 2022-10-28

Published in Print: 2023-02-23

Articles in the same Issue

https://doi.org/10.1515/jpm-2022-0438

Keywords for this article

gynecology; maternal health; obstetrics