Introduction of prenatal ultrasound services in rural Uganda and association with referral patterns and neonatal and maternal outcomes: a combined pre-post and retrospective analysis study
Delia Horn, Abimbola Leslie, Renny Ssembatya, Erika M Edwards, Joyce Nayiga, Frank Williams, Micheal Ssenoga, Alphonsus Matovu, Kristen DeStigterObjectives
To determine the association between prenatal ultrasound (US) services, referral patterns and maternal and neonatal outcomes surrounding delivery in rural Uganda. Our hypothesis was that the introduction of third trimester ultrasound services would lead to more mothers being referred to a higher level of care for delivery.
Design
This study combined data on referrals and health outcomes pre- and post- the introduction of ultrasound with data from a retrospective analysis of Health Center III records.
Setting
This study was conducted in rural Uganda at 7 Health Center III sites (primary care sites) in four districts from June 2022 to October 2023. The study sites included three sites in the West Nile Region, which serves a predominantly refugee population, and four sites in the Southwestern Uganda Region.
Participants
Participants were women who presented for care at the Health Center III sites during the study period and their neonates. All were black African, most were Ugandan citizens. A total of 2861 mothers were enrolled. Complete outcome data were obtained on 2617 mothers and their 2639 infants.
Intervention
The intervention was antenatal ultrasound scans offered during the third trimester of pregnancy.
Primary and secondary outcome measures
Our primary outcome was the proportion of pregnant women referred to a higher level of care. Secondary outcomes included the proportion of neonates receiving neonatal resuscitation in the form of bag-mask ventilation at delivery, proportion of mothers with postpartum haemorrhage within 1 day of delivery, neonatal death within the first 28 days of delivery, stillbirth, Apgar score and maternal death within the first 42 days of delivery.
Results
The introduction of prenatal ultrasound in these rural low-income country settings was associated with a difference in rates of referral to a higher level of care for delivery from 6.0% before introduction of US to 13.6% post-introduction (p<0.0001) as well as in mode of delivery in the study population (p<0.0001). There was an increase in antenatal referrals but a decrease in intrapartum referrals and a decrease in referrals for cephalopelvic disproportion with the introduction of ultrasound. Most mothers who were referred to a higher level of care followed these recommendations. There was a decrease in the proportion of neonatal mortality and stillbirth among mothers who received ultrasounds and were referred to a higher level of care, but this was not statistically significant. There was no difference in neonatal or maternal morbidity or mortality.
Conclusions
The introduction of prenatal ultrasound in a rural low-income country was associated with more referrals to a higher level of care and a change in the timing of referral. The introduction of prenatal ultrasound in this setting may help to identify high-risk pregnancies and to reduce emergent intrapartum transportation.