Abstract
Background:
In 2016, the World Health Organization recommended inclusion of an ultrasound scan as part of routine antenatal care to improve pregnancy outcomes. However, most rural women in Ethiopia do not have access to ultrasound scanning as part of their routine antenatal care. Recently, ultrasonography services were introduced at health centers in Harar, Kersa, and Haramaya districts in Eastern Ethiopia. This expoloratory study aimed to examine experiences of pregnancy surveillance midwives in the Child Health and Mortality Prevention Surveillance (CHAMPS) who performed ultrasonography at health centers that are in the catchment area of Health and Demographic Surveillance Systems, in Eastern Ethiopia.
Objective:
To explor midwives’ experiences across 14 health centers in Eastern Ethiopia, located in the Kersa, Haramaya, and Harar Health and Demographic Surveillance Systems from February to April 2022
Design:
Exploratory qualitative study.
Methods:
The methods used were based on the Standards for Reporting Qualitative Research framework. Purposeful sampling was used to explore experiences of midwives who performed ultrasonography at selected health centers. The Midwives are recurited, trained and stationed at the health ceners to do ultrasound scanning and other activities by the Child Helath and Mortality Prevention Surveillance (CHAMPS) pregancny surveillance activities. Among 17 midwives who had undergone ultrasonography training and who were actively involved in ultrasound scanning at health centers in Kersa, Haramaya, and Harar Health and Demographic Surveillance Systems, three midwives who worked at health centers with no power or near a hospital were excluded. Using tape recordings and note-taking, data were collected through in-depth interviews based on a semi-structured interview guide. Thematic analysis used for data categorization, and the trustworthiness of data was kept throughout the procedure using credibility, dependability, confirmability, and transferability.
Results:
In this study, we identified five main themes: Ultrasonography positively impacts midwives trained as sonographers; performing ultrasound scans enhances the skills and confidence of midwives, improving their professional development, Individual perception of self-efficacy; midwives’ belief in their abilities to perform ultrasound scans effectively influences their job satisfaction and motivation, Provision of care; integrating ultrasound into antenatal care enhances the quality, therapeutic communication, and personalized nature of care provided to pregnant women, Barriers to providing ultrasonography services; challenges such as shortage of ultrasonography-trained staff and workload can hinder the delivery of ultrasound services in rural areas, Community acceptance; the level of community understanding, trust, and support towards ultrasound technology and midwives as sonographers impacts the successful implementation and sustainability of ultrasound services.
Conclusion:
Ultrasonography performed by midwives at rural health centers had a considerable impact on antenatal care services and incareased confidence of midwives.
Plain language summary
The World Health Organization recommends that pregnant women undergo at least four antenatal care (now eight times) visits during their pregnancy. The goal is to reduce feto-maternal complications. Recently, ultrasonography services are introduced in Harar, Kersa and Haramaya districts, Eastern Ethiopia. Midwives who performed ultrasonography at selected health centers were part of this exploaroty study. The information were generated through code, categories, and themes. Five themes were identified. Ultrasonography positively impacts midwives trained as sonographers, individual perception of self-efficacy, provision of care, barriers to providing ultrasonography services, and community acceptance. Ultrasonography performed by midwives at rural health centers had a considerable impact on antenatal care services and midwives confidence.
Keywords
Introduction
Antenatal care (ANC) is one of the most widely used health care strategies worldwide. The World Health Organization (WHO) recommends a minimum of four ANC visits for pregnant women. 1 The goal of this approach is to reduce feto-maternal complications through early detection and management. Increased ANC utilization is one of the strategies to achieve Sustainable Development Goals 3.1 and 3.2, 2 but it is not sufficiently achieved in all countries; according to Ethiopia Demographic Health Survey (EDHS) 2019, only 43% of Ethiopian women had at least four ANC visits, whereas 26% had no ANC visit. 3
Women’s illiteracy and rural residency are common contributing factors to the underutilization of ANC services,4,5 particularly for those less likely to receive all recommended components of quality ANC. 3 Poor health care provision, lack of proper counseling, and lack of basic medical equipment are all common factors influencing the quality of ANC, particularly in rural areas.4,6
ANC must include vaccination, infection screening, and treatment, as well as the identification of risk factors and complications during pregnancy. 1 Adequate health care provision during visits by trained and qualified health care professionals significantly affects the early detection of pregnancy-related complications. Ultrasonography has become an essential component of ANC worldwide.7,8 In 2016, the WHO recommended an ultrasound scan as part of routine ANC. 9 Ultrasonography is used to assess gestational age (GA), rule out multiple pregnancies, assess the quantity of amniotic fluid, screen for fetal abnormalities, determine fetal growth, and assess the placental localization. 9 Ultrasonography may aid in the timely diagnosis and intervention, potentially lowering feto-maternal morbidity and mortality.7,9
In Ethiopia, ultrasonography is available in urban areas and is performed by radiologists and gynecologists. However, women from rural areas cannot access ultrasonography at their nearest health center and are frequently referred to urban areas for ultrasonographic examination, which increases the burden on fetal and maternal health, ultimately increasing mortality. 10 The main difficulty in performing the sonographic examination is the lack of ultrasonography devices and the shortage of radiologists and gynecologists in rural areas. Even in hospitals with ultrasonography devices, the lack of radiologists and gynecologists is a major challenge. 11 However, studies have demonstrated that performing ultrasonography by qualified midwives is useful for the early detection of pregnancy problems, which enhances both the quality of maternity care and client satisfaction. A midwife sonographer would also provide a holistic ANC.11,12 According to an Ethiopian study, almost all midwives agreed that the introduction of ultrasound technology at the health center level improved perinatal health outcomes. 10 Recently, trained midwives through the Child Health and Morality Prevention Surveillance (CHAMPS) preganncy surveillance activity have begun performing ultrasonography examinations at 17 health centers in Harar, Kersa and Haramaay districts in eastern Ethiopia; however, studies to assess midwives’ experiences in this area have not been conducted. Thus, this study aimed at exploring experiences of midwives who perform ultrasonography in health centers in Kersa, Haramaya, and Harar Health and Demographic Surveillance Systems (HDSSs).
Methods
The methods used Standards for Reporting Qualitative Research (SRQR) framework, 13 which consists of 21 items divided into six major categories. The checklist assisted in reporting the introduction of the main aspects, key aspects of the research team, study methods, study context, findings, analyses, and interpretations.
Context/setting
This exploratory qualitative study investigated the experiences of midwives who perform ultrasonography in CHAMPS pregancy surveillance. The research was conducted from February to April 2022 across 17 health centers in Eastern Ethiopia located in the Kersa HDSS, Haramaya HDSS, and Harar HDSS. Ultrasonography by midwives is integrated to the health center as part of the CHAMPS preganncy surveillance mainly to determine the gestational age of the pregancny. The study was conducted for 6 months after the training and deployment in the regular activities.
Ultrasonography training was provided to 17 BSc midwives working in 17 health centers with no other access to ultrasonography services. This training was part of a pregnancy surveillance study that examined feto-maternal complications during pregnancy, as well as maternal and neonatal outcomes during and after delivery, across 17 health centers and three hospitals in the eastern part of Ethiopia.
The goal of the training was to teach midwives how to operate ultrasonography devices, perform antenatal ultrasonography, and read and interpret ultrasonography images. The training was provided to midwives who had no prior experience in scanning, reading, and interpreting ultrasonography images, but they were well-versed in clinical practice and data collection. Senior obstetricians and gynecologists provided a 1-day orientation, and an ultrasonography training manual was offered to all participants. For 1 month, a senior obstetrics and gynecology resident conducted practical training sessions. Each participant was expected to perform 10 ultrasonographic examinations per day under the supervision of a head nurse; abnormal or unclear findings noted by the participants were discussed with senior residents at the end of the day. The overall activity and performance were assessed daily by the coordinator, and professional explanations and suggestions were provided for unclear questions and findings.
Post-training scanning competency was assessed by senior residents using a structured checklist, with the participants expected to score 80% and above. Participants who did not achieve the required minimum score had to repeat the practice for a week, and their competency was reassessed; this was repeated until they achieved the required score. Evaluation competencies included the preparation of pregnant women for ultrasonography, device operation, ultrasound imaging, and reading and interpretation of normal and abnormal findings. Furthermore, the trainers evaluated and rated each trainee on their ability to identify the uterus, adnexa, gestational sac, yolk sac, and fetal cardiac activity and to accurately calculate the mean sac diameter and crown-rump length in the first trimester. In addition to these activities, during the second and third trimesters, the participants conducted assessments, including examination of the placenta, measurement of the cervical length and amniotic fluid, identification of the fetal number and position, and accurate estimation of the biparietal diameter, head circumference, abdominal circumference, and femur length. After successfully completing the training, the pregnancy surveillance study distributed ultrasound devices to the 17 health centers in Kersa HDSS, Haramaya HDSS, and Harar HDSS catchment area. Follow-ups were done for 1–2 weeks to confirm the competency of the trainees until they could perform the ultrasonographic examinations independently.
Research characteristics and reflexivity
The research team included public health and nursing professionals with a minimum educational qualification of MSc. The interview and analytics teams comprised women with PhDs who had previous experience in qualitative research. Before the start of the study, researchers and participants had not interacted and had never met. This measure was aimed at minimizing the impact of the power imbalance between researchers and participants. However, all participants were aware that the interviews were being recorded for research purposes.
Study participants
The study participants were 14 midwives who had undergone ultrasonography training and were actively involved in ultrasound scanning in the study area. All midwives who worked at health centers in the Kersa HDSS, Haramaya HDSS, and Harar HDSS were included, but three midwives were excluded because two of the health centers had no electricity and don’t do ultrasound scanning and one health center was located close to a specialized university hospital, so they mainly use the hospital resources. All 14 midwives who actively participated in ultrasound scanning were included, and purposeful sampling was used to identify midwives working in places where ultrasonography use was limited.
Data collection instruments and procedure
In a natural setting, trained facilitators conducted in-depth interviews while recording interviews on audio tape and taking notes. A semi-structured interview guide was used for the dynamic operation between the researcher and study participants. After reviewing literature and consulting with the research team, an interview guide was formulated. Following multiple discussions, all researchers reviewed the revised version of the guide and reached a consensus before evaluation by the senior researchers. Finally, with the approval of senior researchers, in-depth interviews were conducted. The interviewer was informed on the importance of confidentiality and data use.
Data analysis
The audio recordings were transcribed verbatim into Afan Oromo and Amharic, yielding 25 pages of transcripts that were translated into English for analysis. For the thematic analysis, the first step was to read the transcripts of each interview several times to familiarize the researchers with the content. The second step was to look for meaning units that involved identifying statements containing descriptions relevant to the study’s objectives. This process entailed condensing and preserving the essential meaning of longer units in step 3. The condensed meaning units were grouped and coded in the fourth step. Codes with similar content were sorted into categories, which were further abstracted into themes. The research group held an open and critical dialogue until the final terms were determined, to discover alternative descriptions or interpretations. The analysis yielded five themes, each within its own categories.
Data quality control
The trustworthiness of the data was maintained throughout the procedure by using four common methods such as credibility, dependability, confidentiality, and transferability. After the interview, the interviewer summarized the participants’ responses to increase the credibility of the data and confirm its exactness. The researchers and senior researchers used peer debriefing to assess the credibility of the findings. The interviewer used the same interview guide for each participant to collect data. To address dependability, notes were taken regarding the unusual reactions of the participants. The researchers double-checked the objectives, methods, and procedures to improve the rigor of the research findings. To ensure that the results were consistent, the completed transcriptions were compared with the audio recordings.
Several methods have been employed to achieve a high level of data validity and quality. The importance of confidentiality was emphasized in creating a safe and comfortable environment for participants to share intimate details and engage in a more comprehensive description of their experiences. Transferability was also ensured using a purposive sampling method to enroll information-rich participants, and the researcher attempted to obtain in-depth information during the interview.
Results
Participant characteristics
Participants were female midwives from 14 different health centers, of which 3 and 11 were urban and rural health centers, respectively. All participants held a BSc degree and 4–7 months of sonography experience. Participants’ ages ranged from 25–30 years.
The data analysis revealed five themes: ultrasonography positively impacts midwives trained as sonographers, individual perception of self-efficacy, provision of care, barriers to providing ultrasonography services, and community acceptance (Table 1).
Identified themes with their categories.
Theme 1: ultrasonography positively impacts midwives trained as sonographers
The study participants indicated that training midwives as sonographers is an exciting opportunity because most women in rural areas face several challenges, including poverty, gender inequality or power imbalance, family workload, and lack of attention from partners. Consequently, providing free ultrasonography services near homes can help prevent pregnancy-related problems.
Category 1.1: a sense of fulfillment from helping women
The participants reported that most of the rural women living in poverty were at risk of malnutrition and susceptible to pregnancy-related complications. These women rarely sought available health care, possibly because of financial constraints. Before the implementation of ultrasonography services at health centers closest to their homes, most patients visited health centers only if severe complications occurred, often resulting in premature death. After the introduction of this new ultrasonography service, women visiting the health center for undergoing ultrasonography and receiving ANC during early pregnancy could reduce potential complications. Midwives expressed satisfaction and happiness with this development.
I am very happy to be a midwife and trained as a sonographer because we are assisting women to avoid having babies with congenital defects and facilitating early termination. Early identification of women with abnormal findings, such as placenta location, oligohydramnios, and abnormal fetal heartbeat, prevents the mother and the fetus from experiencing real-life complications, which is very beneficial to both the mother and the community. This excites me, and I am very happy with the results.
Another participant, during an in-depth interview, described her feelings related to community perception.
The interesting thing is that pregnancy is risky by itself, and if one mother carries the fetus for nine months and gives birth to a newborn with severe congenital malformation, she will be isolated from the community for the rest of her life because this is considered a sin in our community, but now we identify those things and refer them for termination. This means that we help women to avoid community prohibitions.
Category 1.2: job satisfaction
The participants explained their feelings about their job by comparing their feelings before and after the ultrasonography service. Before the service had been established, the GA, position, and presentation of the fetus were identified or determined by palpation, which often could not detect abnormalities and caused discomfort to pregnant women. Thus, recruiting volunteer women for examinations was very difficult, and convening women took more time. After the introduction of the ultrasonography service, most women sought ANC to obtain ultrasonography services, which simplified things. Furthermore, assisting women before adverse outcomes occur increased their job satisfaction.
I can hear the fetal heart rate and estimate GA [gestational age] by palpation in the absence of ultrasonography; however, in the presence of anencephaly, the heartbeat is present, so we can conclude that the pregnancy is normal; however, now that we can identify all abnormalities, preventing women from carrying this pregnancy until the time of delivery makes me very proud of my job.
Another participant described job satisfaction as facilitating the early termination of pregnancies after detecting severe congenital abnormalities and preventing their recurrence in future pregnancies.
I can prevent this calamitous occurrence with an ultrasound examination. We counsel the women and refer them to hospitals for termination after identifying the condition, and we counsel the women on how to avoid this complication in the future before becoming pregnant; this gives me a lot of satisfaction in my job.
Another participant described her job satisfaction in comparison with other midwives not having this chance.
As a midwife, I am thrilled to be working on sonography; I would not have chosen this location in the past because I am a midwife. Even at this time, most midwives in health centers and hospitals did not perform ultrasounds; thanks to pregnancy surveillance for giving us this opportunity, we are unique in comparison to our peers, and this is new for midwives. . . . I consider myself fortunate to work with ultrasound because it instills professionalism in me.
Theme 2: individual perception of self-efficacy
Participants in the study asserted a strong link between health centers and hospitals in the study area via midwives assigned to each hospital for pregnancy surveillance. The midwives’ findings consistently aligned with those of gynecologists at the hospital, thereby fostering trust between health centers and hospitals. Hospital midwives communicated the ultrasonographic findings to health center midwives, confirming their scanning and diagnosing capabilities, thereby reassuring them with this feedback.
Category 2.1: perception of ultrasound scanning proficiency
According to the participants, the training was very beneficial. Before this training, the participating midwives were unfamiliar with ultrasound scanning, but after 1–3 months of training, they gained a lot of knowledge and skills, and through practice, they improved their knowledge, skills, and confidence in providing standard antenatal services. In addition to assessing fetal presentation, position, heart rate, GA, as well as identifying multiple pregnancies, midwives successfully detected abnormal findings such as placenta previa, anencephaly, polyhydramnios, oligohydramnios, and congenital abnormalities. One midwife also discovered a fetal abdominal cyst.
I can measure fetal factors such as fetal heartbeat, amniotic fluid volume, fetal presentation, placental position, and, most critically if there are any congenital defects such as spinal bifida based on the training I obtained. We saw those cases practically throughout training, so I can distinguish them using ultrasonography.
I also know how to measure the amount of amniotic fluid to see if it is at normal, below, or above the expected amount.
Another participant described that her skills improved through practice.
I learned a lot from the training and improved my skills through practice, so I am now very confident that I can identify abnormalities such as abnormal placental location, hydrocephaly, anencephaly, the abnormal volume of amniotic fluid, intrauterine growth retardation, and intrauterine fetal death, as well as estimate GA [gestational age], identify fetal presentation and position.
Another participant described how training made ultrasonic scanning simple.
Previously, as everyone is aware, ultrasound was not performed by midwives. Ultrasound was perceived as a difficult task, but with proper training and practice, it became straightforward, and with sufficient exposure, you may be able to master it. The task may seem difficult without prior but once you have received training, it is simple to complete the entire task, which is also very interesting.
Category 2.2: sense of confidence in communicating the findings
The respondents noted that before the ultrasonography, they were skeptical about communicating the physical examination findings. Most of the time, there is a discrepancy between what the midwives find at the health center and what the pregnant women are being told at the hospitals, which reduces trust in the health center’s care and makes the midwives less confident in their work. However, since the start of this ultrasonography service at the health center, they have become more confident in communicating the findings to women.
We can hear the fetal heart rate and estimate GA [gestational age] in the absence of ultrasound; however, in the presence of anencephaly, for example, the heartbeat is present, so we can conclude that the pregnancy is normal; however, if the women discover this abnormality at the delivery time or during the pregnancy if she has the chance ultrasound at the hospital during this time, they lose their trust of the care provided at the health center.
Another participant expressed her increased confidence in reporting the findings.
Interestingly, you can tell the mother about the condition of the fetus without a doubt; our findings are almost 100% consistent with the hospital; we have ongoing information through phone conversations with midwives who work in the hospital; as a result, now ANC visits to health centers have increased because women have trust our findings.
Theme 3: provision of care
Being midwives and trained sonographers allows the study participants to provide quality and holistic care while also improving communication between midwives and pregnant women, resulting in better outcomes.
Category 3.1: quality prenatal health services
Most participants (12 out of 14) expressed the belief that ultrasonography was beneficial in ANC, contributing to increased trust and facilitating care management. They stated that, compared with preultrasonographic care, the quality of ANC improved in terms of women’s satisfaction, timely accessibility, and accuracy of the conclusions.
I can say that the quality of maternity care has improved because, unlike before the ultrasound, we can now identify any complications early and facilitate management with the help of health center staff. The women are also overjoyed with the service they received.
Category 3.2: therapeutic communication
The participants stated that ultrasonography services improved communication between midwives and pregnant women because midwives perform their jobs with satisfaction and confidence, and pregnant women, particularly those from rural areas, have a high level of trust in ultrasound scanning. The participants answered the women’s questions about fetal health and development. They reassured women and their families about the absence of abnormal findings and, in case of abnormalities, facilitated referrals to the hospital in collaboration with midwives assigned to maternity care. Furthermore, they facilitated the early management of complicated cases by communicating with midwives working for pregnancy surveillance at hospitals.
Recently, I detected anencephaly and polyhydramnios, after detecting and confirming the presence of abnormalities, I called the head of midwives to communicate the results to the woman. Initially, we placed her in a comfortable environment and informed the woman that we needed to discuss the findings with her. At that point, she had no prior knowledge about the baby. However, when she learned about the baby, she cried and expressed significant concern, particularly in relation to the excess fluid, which was a symptom she had experienced. The maternal reaction is extremely upsetting for me because hearing such news as a mother is very painful. We reassured her and advised her to see an obstetrician before agreeing on a referral. The following day, she arrived with her husband, obtained a referral form, and went to the hospital, where the pregnancy was terminated.
Another participant described how reassurance was connected to community perceptions.
I recently discovered a case of hydrocephaly and discussed it with the mother. I began my discussion with a very general issue, and then I made it more specific with strong reassurance by explaining that this can occur in some pregnancies. At first, she was shocked, but I assured her that she was not the first woman to have this experience and that it had nothing to do with sin, and we discussed the reason for the referral. Then, we communicated with our hospital staff to facilitate early management. Finally, the pregnancy was terminated.
Category 3.3: comprehensive care
The participants stated that their roles as midwives and sonographers enabled them to provide holistic care to women during ANC. They viewed their responsibilities in terms of not only terms of detecting abnormalities but also considering the psychological and social aspects of women’s well-being. During referral, they discussed the intervention and expected outcomes at the hospital. Furthermore, they arranged follow-ups at home for women identified at risk. Based on the ultrasonographic findings, midwives discussed the women’s lifestyle choices, such as diet during pregnancy, number of ANC visits, and the best way to avoid severe complications.
In the absence of ultrasound, we can hear the fetal heart rate and estimate GA [gestational age]; however, in cases of anencephaly, the heartbeat is still present, potentially leading to a misinterpretation of normalcy; however, now that we have identified all abnormalities, we should refer the women to the hospital as soon as possible. We also educate people about the possible causes of this abnormality and how to avoid it. As a result, ultrasound helps us provide more comprehensive care.
Another participant made mention of their home visits.
It is difficult to communicate with the mother about abnormal findings, especially when they are severe; for example, one day I had a case of anencephaly, and the pregnancy was a term with no ANC, so I discussed it with the staff midwives, and we called her husband and brother to inform them that this can happen for a variety of reasons that are not related to sin. The woman and her family were then reassured and referred to the hospital. During the home visit, the fieldworker gave health education on ANC, diet during pregnancy, and also how she prepared herself for the next pregnancy.
Category 3.4: midwives are the frontline health care providers for pregnant women in rural areas
According to the participants in this study, there was a lack of radiologists and gynecologists in rural health centers, which caused women to receive inadequate care. They had to travel long distances and spend more money on ultrasonographic examinations, but most women lack the financial means to do so. As a result, they remain silent about their illness at home. This can have serious and irreversible health consequences. Midwives are now close to women in rural areas, and training midwives as sonographers is one of the best ways to avoid such problems.
Midwives are available in rural health centers, but other professions such as physicians or gynecologists are not, so it is preferable if midwives take on the responsibility of performing ultrasounds because women from rural areas suffer from various pregnancy-related complications and cannot afford the cost of transportation and ultrasound, so they keep silent with abnormal findings until birth. Furthermore, when neonates with severe congenital abnormalities are born, it is embarrassing in rural areas. Having this ultrasound close to their village reduces this all, and because midwives are found closest to rural communities, I recommend that midwives should perform the ultrasound for a better outcome.
Theme 4: barriers to providing ultrasonography services
Participants in this study stated that ultrasonography services are widely available in Ethiopian health centers and that they greatly value having this service at their health center. However, they identified several obstacles when implementing the service, including the lack of space, rooms located far from maternal and childcare clinics, and power outages. The most common barriers are identified under the themes discussed below.
Category 4.1: shortage of ultrasonography-trained staff
Each selected health center has one midwife who received ultrasonography training. This is insufficient, and ultrasonography training for at least one additional midwife should be provided. Furthermore, this service is supported by pregnancy surveillance; the participants wondered what would happen if this surveillance program was stopped at some point; therefore, the health center should consider training their staff and make efforts to keep this service operational.
One midwife is insufficient to perform the ultrasound; training should be provided to other midwives by pregnancy surveillance staff or health center staff so that if one who performs the ultrasound encounters a problem, the rest can substitute and sustain the service; otherwise, if this person is absent due to any reason, the service will be disrupted for a while.
Another participant expressed skepticism about the sustainability of the implemented ultrasonography service.
The community is very pleased with this service, but I am always concerned that if this surveillance is discontinued, will the service continue? As a result, the health center should consider this. They should provide staff training to keep the service running.
Category 4.2: workload
Six out of twelve participants complained about their workload, particularly during the market hours, when they became very busy with ultrasound scanning and data entry. This prompted the participants to seek assistance. Most pregnant women visit the health center on market days amid their busy buying and selling activities; thus, the women are always in a rush to receive health care services. They are often unwilling to wait for the scan and data entry during this busy time, which creates conflicts among the staff.
Another midwife should be trained to assist me because the number of clients becomes uncontrollable during market hours. I find myself occupied with performing ultrasounds and entering data. As a result, I require assistance, particularly at this time.
Theme 5: community acceptance
According to the participants’ reports, the number of women who attended ANC services before the start of ultrasonography was minimal. To increase coverage, the health professionals conducted several activities in the community, such as monthly community mobilization for ANC through health education at health centers and community health education through gatherings. However, there was no significant change in ANC visit coverage. In addition, the number of women who visited the health center and used ANC services doubled after the commencement of ultrasonography services because of the increased acceptance of ultrasonography among the community members.
Category 5.1: women’s emotions
The participants asserted that, previously, most women from rural areas faced challenges in accessing ultrasonography services. However, with the introduction of payment-free ultrasonography near their community, they are now happy, motivated to visit ANC, cooperative in accepting the advice from health care professionals, and have a high level of trust in the service.
ANC has increased following the launch of this ultrasound service. Before the implementation of this ultrasound, the health worker provided health education at the community level once a month to increase ANC visits; however, in the absence of any education, ANC visits have increased.
Another participant noted an increased level of trust among women in ANC services.
Before the ultrasound service, the women did not trust our findings because they did not always match with the findings they received at the hospital. Even if a single woman experienced such discrepancies, word would spread within the community, leading to a discouragement of people from visiting the health center. However, thanks to ultrasound, our findings are now identical to those of the hospitals, and they are overjoyed.
Category 5.2: reducing community taboos
Ultrasonography services significantly reduced community taboos. As a result, the majority of study participants shared that most women from rural areas did not have access to ultrasonography due to transportation and ultrasonography costs. Newborns with severe congenital abnormalities are a common occurrence and a major taboo in the community. They associate this condition with the mother’s or family’s sin. Consequently, these women are frequently isolated from the community, and divorce is a common occurrence.
Our community believes that congenital malformations occur as a result of Allah’s punishment for their sin. If one woman gives birth to a baby with an abnormality, it is considered a family sin. So, ultrasound relieves women’s stress because it detects this condition early and termination occurs before giving birth.
Discussion
Ultrasound-guided ANC in rural health centers is critical for increasing ANC utilization and improving perinatal health outcomes; however, rural women often lack these opportunities because the service is not commonly available at health centers and is not included in routine ANC at hospitals. 10 However, ultrasonography services have recently begun under ANC in the Harar, Haramaya, and Kersa HDSS health centers in the East Hararghe Zone. This study aimed to explore the experiences of midwives who performed ultrasonography across various health centers in the East Hararghe Zone. In this study, we identified five main themes: ultrasonography positively impacts midwives trained as sonographers, individual perception of self-efficacy, provision of care, barriers to providing ultrasonography services, and community acceptance.
According to midwives, performing ultrasonography at a health center is an exciting and enjoyable event because it involves saving women from unfavorable pregnancy outcomes that can potentially result in fetal or maternal death. Women from rural areas face several issues that must be addressed quickly to reverse negative outcomes. Helping these women brought a significant sense of satisfaction among the midwives. This finding is consistent with that of a previous study conducted in Norway that showed that participants enjoyed working as sonographers. 12
According to the descriptions of participating midwives, the intensive training was very effective in acquiring knowledge and skills, which they further developed through practice. Their ultrasonographic findings confirmed by health care professionals at hospitals provided an excellent opportunity to boost confidence. Previous studies have found that ultrasonography training is beneficial and improves knowledge, skills, and confidence in providing standard prenatal services.10,14
Most study participants believed that providing ultrasonography at the ANC improved care quality, facilitated therapeutic communication, and provided comprehensive care. The study participants stated that instead of estimating the fetal condition using manual methods, they could use ultrasonography to identify abnormalities and provide quality care while making early and informed decisions. Concerning the ultrasonographic findings, midwives maintained close contact with the women and their families during the ANC visit and at home to address the psychological and social aspects of their health. This is consistent with the findings of a study conducted in Ethiopia, which discovered that ultrasonography generates useful information for evidence-based decision-making, referral service arrangements, and the continuation of follow-up services within a health center.10,14 A study from Norway also indicated that ultrasonography was vital for providing holistic care to pregnant women, their partners, and unborn children, rather than focusing solely on the technical aspects of ultrasonographic examination. 12
Respondents agreed that midwives are frontline providers for pregnant women in rural areas. Due to the lack of gynecologists, midwives are the backbone of maternity care at rural health centers, providing nearly all care. As a result, they have the closest relationships with women and the community. Therefore, ultrasonography performed by midwives is very effective in providing holistic care to pregnant women. According to a Rwandan study, midwives expressed a desire for ultrasonography training because no full-time physician was working at their health centers. Participants saw the potential for midwives and nurses to be trained in ultrasonography. 15
The most common barriers encountered by participants during their experience were a lack of trained personnel and heavy workloads. The participants claimed that, in addition, trained midwives were required to provide the service without interruption, and they expressed concerns about the sustainability of this service because it was established as part of pregnancy surveillance. They strongly advised health centers to focus on accepting responsibility and maintaining services. This finding is supported by studies from Mozambique and Ethiopia, which demonstrated that remote ultrasonography training in rural settings is feasible, efficient, and sustainable. This can assist local health care workers in screening their prenatal populations for obstetric and neonatal risks, potentially improving delivery outcomes.14,16 Doctors testified in the Rwandan study that, due to a shortage of physicians in many, particularly rural, areas, midwives, or nurses were forced to manage complicated deliveries, putting a lot of responsibility on their shoulders. 17
According to the participants of our study, the ultrasonography service was well-accepted by the community because it was free and close to the homes of pregnant women. It has been reported that women are very satisfied with this service. Furthermore, it prevents women from having children with severe congenital malformations, which is considered to be related to sin by these communities. This finding aligns with those from a study in Southern Ethiopia, in which almost all participants expressed high community acceptance of and demand for ultrasonography services. 10
Strengths and limitations
This study recruited participants from three HDSS cathcment health centers in East Ethiopia, providing in-depth experiences and the use experienced data collectors for precise information. This study did not explore the experiences of women who received care.
Conclusion
This study highlights the positive impact of midwives performing ultrasonography on ANC delivery and midwife confidence. Our study suggests that midwives enjoy their jobs because they contribute to avoiding complications during pregnancy, at birth, and after birth. They are very proud to be midwives trained as sonographers. Ultrasonography allows women to receive holistic care, encouraging them to attend multiple ANC appointments. Receiving feedback from referral hospitals boosts their confidence and facilitates the community acceptance of ANC at health centers. Because midwives are frontline health care providers at health centers, ultrasound scanning at this level increases their positive communication with women, resulting in greater community acceptance.
Supplemental Material
sj-docx-1-whe-10.1177_17455057241228135 – Supplemental material for Midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study
Supplemental material, sj-docx-1-whe-10.1177_17455057241228135 for Midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study by Maleda Tefera, Haymanot Mezmur, Mohammed Jemal and Nega Assefa in Women’s Health
Supplemental Material
sj-docx-2-whe-10.1177_17455057241228135 – Supplemental material for Midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study
Supplemental material, sj-docx-2-whe-10.1177_17455057241228135 for Midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study by Maleda Tefera, Haymanot Mezmur, Mohammed Jemal and Nega Assefa in Women’s Health
Supplemental Material
sj-docx-3-whe-10.1177_17455057241228135 – Supplemental material for Midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study
Supplemental material, sj-docx-3-whe-10.1177_17455057241228135 for Midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study by Maleda Tefera, Haymanot Mezmur, Mohammed Jemal and Nega Assefa in Women’s Health
Footnotes
Acknowledgements
The authors acknowledge all the study participants for their unreserved support in providing information and the data collectors for their endurance during the data collection process. We would also like to extend our thanks to health center staff working for their tremendous support during data collection.
Declarations
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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