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.

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:

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

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.

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 cost-effective method to further enhance maternal and child health (Kinnevey et al. 2016).

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 low- and 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). Furthermore, obstetric ultrasound increases diagnostic accuracy (Kozuki et al. 2016) and offers appropriate diagnosis and interventions (Barnfield, Bamfo & Norman 2019; Holmlund et al. 2017), thus allowing for timeous referrals. Induced labour can be reduced with the use of ultrasound by providing accurate gestational age assessments (Holmlund et al. 2019). Ultrasound is encouraging, complements clinical assessments and enhances clinical decisions (Shaw-Battista et al. 2015). This allows for improved pregnancy management, adequate preparation for labour and birth and reduces the number of surprises for women and healthcare workers at birth (Kinnevey et al. 2016).

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.