Obstetric ultrasound training programmes for midwives: A scoping review

Background Antenatal care is essential for all expectant mothers and assists in reducing maternal mortality rates thus addressing the Sustainable Development Goal 3. Obstetric ultrasound complements antenatal care and is used in pregnancy to identify and monitor high-risk pregnancies. However, disparities exist and in low- and middle-income countries, ultrasound services are not readily available. This contributes to maternal and neonatal morbidity and mortality within these populations. Short ultrasound training programmes for midwives can be beneficial in alleviating some of the challenges experienced. Aim The aim of this scoping review was to identify global ultrasound education programmes for midwives. Method Articles containing suitable keywords were retrieved from databases suitable to nursing, education and ultrasound. Themes were developed based on the articles included in the review. Results A total of 238 articles were identified, and after the duplicates and irrelevant studies were removed, 22 articles were included. Articles were analysed and discussed under the identified themes and categories. Conclusion It is essential that sufficient training is provided to medical professionals performing obstetric ultrasound so that adequate and safe care is offered to expectant mothers. With the introduction of ultrasound in low-resource settings, the knowledge of safety and competencies required to operate the equipment necessitate adequate training. Developed programmes have been found to meet the demands of the ever-changing workforce and allow for midwives to perform focused obstetric ultrasound examinations. Contribution This scoping review highlighted ultrasound training programmes for midwives and provided guidance on the development of future midwifery ultrasound training programmes.

Introduction diagnostic ultrasound service, many pregnant women in lowand middle-income countries do not have access to ultrasound imaging even though the value of obstetric ultrasound has been extensively documented (Vinayak et al. 2017).
Ultrasound training and availability vary within and between countries, and all pregnant women are not afforded equal opportunities because of the existing disparities. Within South Africa, sonographers are trained through higher education learning institutions and, once qualified, are able to conduct a wide variety of ultrasound examinations; however, there are no formal or standardised ultrasound training programmes available for midwives. Midwives are the primary providers of antenatal care and are often the first contact for many expectant women and thus play an important role in the care of expectant mothers and their babies. Thus, the introduction of ultrasound training programmes for all healthcare workers including midwives is warranted. The safety and accuracy of ultrasound in pregnancy have been established if used correctly by trained healthcare professionals and offer valuable information in diagnosing and managing pregnant patients.
The aim of this scoping review was to identify and report on worldwide ultrasound education programmes for midwives.

Methods
The Joanna Briggs guidelines on the methodology applicable to scoping reviews were followed. The scoping review was guided by answering the following research question: What obstetric ultrasound education do midwives receive globally? A further sub-question was asked: What is included in an ultrasound curriculum for midwives?
The following steps were applied: • Identify the research question • Identify relevant studies • Study selection • Charting the data • Collating, summarising and reporting the results • A scoping review was conducted and identification of relevant studies.
A methodical electronic search was undertaken to recognise the available literature on midwifery ultrasound training programmes globally between January 2010 and June 2020. The keywords used to search databases were 'midwives', 'obstetric ultrasound' and 'education/training'. These keywords were grouped together, allowing for an allinclusive search. Databases searched were Scopus, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL -hosted within Ebscohost), Education Resources Information Centre (ERIC), and ProQuest.

Study selection
Ultrasound training for midwives was strengthened after the year 2010, and thus English literature that was published between January 2010 and June 2020 was included. Furthermore, this allowed for an identification of the current practices. Records that were identified were screened for duplication, and all duplicates were removed from the initial search. All full-text records were screened for eligibility and relevance to the research question based on the title or abstract. Subsequently, all full-text records remaining were further reviewed and screened for suitability. This process is demonstrated in Figure 1.

Charting the data
A Microsoft word document was used to gather applicable data from the studies selected. As demonstrated in Table 1, each category was completed in a separate column and included the following: • The authors • The aim and/or purpose • The population and setting • The design and findings.
Data collection, summary and reporting of findings.
A total of 22 studies were included. Findings were contextualised by year of publication, article distribution in journals, geographical distribution and author collaborations. Furthermore, through the process of thematic analysis, emerging themes and categories were identified.

Ethical considerations
Ethical Clearance Certificate (R14/49) was provided by the Human Research Ethics Committee (Medical), University of the Witwatersrand.

Results
The primary search produced 238 articles. After removing the duplicates, 132 articles were screened for eligibility and  • Barriers in low-resource settings have been identified as a cause of perinatal mortality and morbidity in low-resource settings • Training midwives in low-income countries to perform focused obstetric ultrasounds is a practical option and will address staff shortages. Four studies were part of the larger multinational cross-country ultrasound study (CROCUS), which explored the experiences and views of midwives and obstetricians in low-and middle-income countries with regard to the use of ultrasound and pregnancy management. Seven papers were pilot and prospective observational/ cross-sectional studies, respectively. Two studies were reviews. One study was an online survey, and one was a cluster randomised trial.
As demonstrated in Figure 2, 15 (68%) of the studies included were from Africa, while 3 (14%) of the studies were from North America and Asia, respectively, and only 1 (4%) study was from Europe.
As demonstrated in Figure 3, an increase in article publication was noted between 2016 and 2020 with 68% of the articles published during this time frame. Thirty-two percent of the articles included were published between 2010 and 2015.
Sixty-four percent (n = 14) of the articles included in the study are from the following journals, one from each: There were 27% (n = 6) of the articles published in ultrasound and radiology journals, while 9% (n = 2) of the articles were published in PLOS ONE. All included articles were co-authored.

Discussion
Once the data were collected, the process of data analysis began. As demonstrated in Table 2, through the process of thematic analysis, the following themes and sub-themes were identified.
Fifteen articles identified barriers to the use of ultrasound. Task sharing and including ultrasound training by extending the role of midwives were identified in all studies. All articles also identified that the use of obstetric ultrasound improves antenatal care. Ultrasound training methods for midwives were included in all of the studies.

Theme 1: Barriers
Trained users are able to interpret ultrasound findings and provide an adequate diagnosis, thus facilitating referrals and improving pregnancy management and outcomes. However, the most significant challenge and barrier identified with the use of obstetric ultrasound is the lack of education and training programmes specifically for midwives (Dornhofer et al. 2020). The lack of this specific training programme is brought about by insufficient trained and skilled healthcare professionals (Bentley, Hexom & Nelson 2015;Holmlund et al. 2018). Ultrasound is operator dependent, and ultrasound used by inadequately trained healthcare professionals can lead to negative outcomes and false positives (Holmlund et al. 2018). Providing appropriate and adequate training to midwives is of utmost importance, as the production and interpretation of the ultrasound image are directly associated with the training received. Providing an adequate and timely diagnostic ultrasound service is known to improve pregnancy management and outcomes (Baj, Dubbins & Evans 2015); however, because of the shortage of trained healthcare professionals, the ability to provide this service in all settings is compromised (Swanson et al. 2014). Because of these factors identified, ultrasound services are not readily available in all settings. Thus, introducing training programmes allows for healthcare professionals to offer equal antenatal services to all expectant mothers.
In the past the complexity, cost (McClure et al. 2014) and size of the ultrasound equipment were identified as a challenge; however, with the advances in the development of ultrasound equipment, the affordability, the portable compact size as well as the robust nature of this technology, introducing ultrasound in all settings has become a viable option (Kimberly et al. 2010). Furthermore, the image quality on these portable compact machines is of an acceptable standard, and these units if used correctly by trained healthcare workers are capable of providing images of a suitable diagnostic quality.

Theme 2: Task sharing
Task sharing is a safe and applicable method used to reallocate tasks from highly trained professionals to professionals trained in a short period with lower qualifications (Vinayak & Brownie 2018). Task sharing addresses gaps in the workforce among healthcare workers (Vinayak & Brownie 2018) and can increase the accessibility of ultrasound services because of the lack of trained medical professionals (Kozuki et al. 2016), thus addressing the unequal distribution and availability of this service. Furthermore, referrals can be reduced if all midwives are equipped with this important and significant skill thus reducing the burden to an already strained healthcare system. Offering standardised training and support will result in successful task sharing.
Midwives are frontline healthcare workers that offer antenatal services and are thus the ideal population to offer ultrasound training to. It has been demonstrated that midwives after having received appropriate training are able to use portable ultrasound machines to perform basic obstetric ultrasound scans and incorporate ultrasound into their daily practice (Kimberly et al. 2010). Furthermore, it has been demonstrated that midwives are able to accurately determine gestational age if suitable training is provided (Boamah et al. 2014). Thus, training midwives to perform obstetric ultrasound is a suitable (Dolo et al. 2016) and costeffective method to further enhance maternal and child health (Kinnevey et al. 2016).

Theme 3: Improving antenatal care
Differences in maternal mortality and morbidity rates between high-and low-income countries are attributed to the lack of antenatal care and the limited access to healthcare facilities (McClure et al. 2014). An identified priority for lowand middle-income countries include timely identification and diagnosis of pregnancy-related complications (Kozuki et al. 2016). Obstetric ultrasound is an essential element of   antenatal care in the developed world and can improve pregnancy management in high-risk pregnancies (Åhman et al. 2018) and reduce perinatal mortality and morbidity rates if introduced routinely in the developing world (Holmlund et al. 2018). Furthermore, it is essential that sufficiently trained healthcare workers provide antenatal services to patients to assist in reducing maternal and neonatal mortality rates (Holmlund et al. 2017).
A basic obstetric ultrasound scan is identified as an important tool in the management of pregnancies (Edvardsson et al. 2016) and further improves the accuracy of physical examinations. The routine use of obstetric ultrasound is able to identify pregnancy complications and possible high-risk pregnancies that could be missed with a clinical examination (Swanson et al. 2014

Theme 4: Ultrasound training programmes
Ultrasound education and training programmes for midwives have been conducted using various training methods (Fullerton et al. 2019) and time frames. These include didactics, hands-on training, distance online training programmes and formal site-based training programmes. Furthermore, written learning objectives, a skills checklist and the supervision of practical competencies were included (Shaw-Battista et al. 2015). Training programmes varied, however, included aspects of equipment maintenance, ultrasound physics, normal and pathological anatomy of the mother and the foetus, image storage, appropriate reporting methods and basic communication skills between the patient and the healthcare worker (Kinnevey et al. 2016).
Majority of the training programmes includes training midwives to perform basic obstetric ultrasound scans. An important aspect of training programmes is the inclusion of the diagnostic capabilities and ethical responsibilities of the end user to ensure a diagnostic ultrasound service (Holmlund et al. 2019). Short focused ultrasound training programmes of varying duration ranging from 1 week to 6 months (Boamah et al. 2014) have demonstrated high sensitivity and specificity (Barnfield et al. 2019). Conducting practical assessments as part of training is strongly supported and confirms that midwives have obtained the skill and training required to practise independently thus providing this service to a greater population (Fullerton et al. 2019). Post-training assessment methods indicate that knowledge gained through the training programmes was retained, thus further indicating the success in training midwives. Furthermore, ongoing mentoring was identified as an important aspect for the sustainable training of midwives (Shah et al. 2020). Training programmes have demonstrated that midwives are able to develop self-confidence and skills after participating in a structured ultrasound training programme. Furthermore, midwives are able to execute the required task and identify high-risk pregnancies.

Conclusion
Over recent years, the midwife's role has advanced and grown substantially to keep up with societal demands, expectations and the everchanging workforce, by incorporating focused obstetric ultrasound training programmes for midwives (Shaw-Battista et al. 2015). Studies demonstrated that midwifery ultrasound services and tertiary led ultrasound services are comparable (Fullerton et al. 2019), and thus, the key to a successful training programme is standardisation.