Table 3 Summary of the Literature on Ultrasound Training Programs

Stanton K and Mwanri L, 2013 [7]

Low resource settings

Not Applicable

Not Mentioned (Varies by Study)

Systematic review.

Midwives and birth attendants can be trained in ultrasound

32 articles

Not Mentioned

LaGrone LN, Sadasivam V, Kushner AL and Groen RS, 2012 [18]

Low- and middle- income countries

Not Applicable

Not Mentioned (Varies by Study)

Review article.

Generalist and obstetric physicians perform most ultrasound scans.

The types of ultrasonography training ranged from “no formal training to formal certification and residency programs.” (p. 808)

All programs had courses that consisted of didactics and hands-on sessions.

The types of follow-up training ranged from “none, to telemedicine case review, to formal re-evaluations and intensive refresher courses.” (p. 809)

Although ultrasound training in LMICs often does not meet the WHO criteria, select programs reported high levels of diagnostic accuracy and trainees’ knowledge retention.

41 articles for final review

Not Mentioned

Carrera JM, 2011 [31]

Africa

Not Applicable

Not Mentioned (Varies by Study)

Review article.

Most practitioners in Africa are not well-trained in ultrasonography.

40.4% have only received a theoretical short course.

38.3% did not have training.

14.9% received a practical course.

Not Mentioned

Not Mentioned

Kimberly HH, Murray A, Mennicke M, Liteplo A, Lew J, Bohan JS, et al. 2010 [6]

Zambia

6 months

SonoSite 180 portable ultrasound,with an extra battery, a curved array abdominal probe and software for image storing

Quantitative study - no control group included. Observed examinations conducted at midterm and at the end.

“Most recorded scans were performed in second and third trimester.” (p. 1269)

21 midwives underwent three training periods which were 2 to 3 weeks in length and were separated by 2 to 3 months of independent scanning. Training took place in the form of didactic sessions, practical hands on sessions and supervised scanning.

The training content included identification of fetal presentation, fetal heart rate, placental location, multiple gestations, and estimation of gestational age based on biparietal diameter and femur length.

96% agreement between expert reviewers and trained midwives on Interpretation of fetal heart rate.

91% agreement between expert reviewers and trained midwives on identification of placental location.

70% disagreement between expert reviewers and trained midwives on measurement of biparietal diameter.

Clinical decision-making changed in 17% of the cases.

441 scans performed

SonoSite donated ultrasound machines

Wylie BJ, Kalilani-Phiri L, Madanitsa M, Membe G, Nyirenda O, Mawindo P, et al. 2013 [8]

Malawi

4 months +

SonoSite 180 portable ultrasound

Quantitative study - no control group included. Comparison of ultrasound-aided dating and menstrual gestational age/postnatal Ballard estimation.

“61.8% of the subjects were enrolled and imaged between 20 and 27 weeks. 21.3% were imaged after 28 weeks. 16.3% were imaged prior to 20 weeks.”

8 trainees (four research staff, one nurse, three midlevel clinicians) went through an intensive one-week ultrasound training for performing fetal biometry. Four months of additional practice and remote image review followed.

Only 5.7% of the ultrasound scans with a biometric parameter were considered unacceptable.

Ultrasound helped improve gestational age dating in over a third of the research subjects (compared to menstrual dating).

The median gestational age determined by ultrasound dating and by postnatal Ballard estimation were significantly different.

The trainees did not become proficient immediately after the first one-week training course. An additional four months of practice and remote image review were paramount in achieving the necessary skill.

178 patients

Ultrasound machines donated by Vincent Department of Obstetrics and Gynecology at the Massachusetts General Hospital with a matching grant from the SoundCaring Program (Sonosite). Research supported by the Doris Duke Charitable Foundation and by the National Institute of Health.

Rijken MJ, Lee SJ, Boel ME, Papageorghiou AT, Visser GH, Dwell SL, et al. 2009 [32]

Thai-Burmese border

6 months

Toshiba Powervision 7000 machine with a 3.75-MHz convex probe

Quantitative study - no control group included. Intraobserver and interobserver variations measured.

Ultrasound was performed on every fifth pregnant woman with a singleton pregnancy between 16 and 40 weeks’ gestation and who had undergone an early dating ultrasound scan, attending the antenatal clinic.

Four local health workers received a 3-month course consisting of practical and theoretical training in obstetric ultrasound.

The training curriculum was developed based on the World Health Organization guidelines and British Medical Ultrasound Society recommendations.

Compared with the skilled sonographer, the trainees’ fetal anthropometric measurements showed high level of agreement.

349 patients

Ultrasound scanner donated by Ph. Stoutenbeck and the Department of Obstetrics of the University Medical Center Utrecht, The Netherlands. NIHR Biomedical Research Program funded A.T.P.

Kozuki N, 2015[5]

Kozuki N, Mullany LC, Khatry SK, Ghimire RK, Paudel S, Blakemore K, et al. 2016 [52]

Nepal

7 months

Sonosite Nanomaxx system, and a C60n (obstetric) probe

Quantitative study - control group included for comparing facility delivery rates and rate of adverse outcomes.

Pregnant women who were gestational age 32 weeks or more and consented to participate in the study were visited in their homes.

Three auxiliary nurse midwives received two one-week ultrasound training sessions which were separated by a month. Training took place in the form of lectures, demonstrations and practice.

The training content included identification of fetal presentation, fetal heartbeat, multiple gestation and placental position.

The “cannot determine” selection by two reviewer teams for fetal presentation was 0.1 and 0.3% of the ultrasound exams.

The “cannot determine” selection by two reviewer teams for multiple gestation was 0.9 and 6.6% of the ultrasound exams.

The “cannot determine” selection by two reviewer teams for placenta previa was 34 and 44% of the ultrasound exams.

804 women

Children’s Prize, the National Institutes of Health/ National Institute of Child Health and Human Development, Bill and Melinda Gates Foundation. Ultrasound machines donated by SonoSite Soundcaring Program.

Stein W, Katunda I and Butoto C, 2008 [27]

Tanzania

12 months

Siemens SL-1, with a 3.5 MHz/5 MHz sector probe and a 8 MHz vaginal probe

Quantitative study - no control group included. Clinical diagnosis compared with ultrasound-aided diagnosis.

The first-level ultrasound was randomly conducted on patients with absent fetal heartbeat and suspect fetal position other than cephalic. For suspected twins and vaginal bleeding, it was regularly re-examined. The second-level advanced ultrasound was performed by a specialist sonographer for patients with fundal height discrepancies, suspected incomplete abortion, suspected extra uterine pregnancy and abdominal pain.

Midwives received two months of training in basic obstetric ultrasound to perform first-level ultrasound services.

Trained midwives identified twins, fetal heart rate and fetal position with 100% agreement as the sonographer.

The results for vaginal bleeding agreed in 76.6% of the cases between midwives and the sonographer.

542 patients

Not Mentioned

Bell G, Wachira B and Denning G, 2016[33]

Kenya

15 months

Not Mentioned

Quantitative study - no control group included. Trainees’ mean scores were compared across sessions.

Trainees were given materials to study before the workshop. They then participated in three all-day workshops held every 3 to 5 months. Training included review of content for point-of-care ultrasound (“the abdominal, pleural and cardiac assessment for free fluid, the thoracic exam for pneumothorax, an obstetric exam for intrauterine pregnancy, cul-de-sac fluid, fetal heart activity and position” - p. 2), demonstrations and practice. Professional cadres of trainees included clinical officers, doctors and nurses.

After the workshop, participants demonstrated increase in knowledge and acquisition of practical skills.

Average scores for practical skills were not significantly different among varying cadres of healthcare workers.

81 trainees

The Christian Health Association of Kenya provided training facilities,

DAK Foundation provided ultrasound equipment, The Emergency Medicine Kenya Foundation, The Emergency Medicine Department at the University of Iowa and The Aga Kahn University Hospital provided funding support.

Greenwold N, Wallace S, Prost A and Jauniaux E, 2014 [34]

Mozambique

12 months

Sonosite 2 M-Turbo portable ultrasound, with integrated obstetric biometric charts

Quantitative study - no control group included. Detection rates for trainees under supervision and without supervision were compared.

All women attending prenatal care between 11 weeks and term were offered ultrasound exams.

9 nurses and clinical officers underwent an 8-week training course followed by 10 months of remote supervision. Training included 1 week of formal lectures and 7 weeks of practical hands-on sessions.

The training content included basic uses of ultrasound, first-trimester ultrasound, estimation of gestational age and identification of fetal presentation, placental position, multiple pregnancies and uterine fibroids.

Comparison of the detection rates for basic ultrasound findings between the two groups reveals that fetal anomalies are the only condition that the participants under direct supervision detected significantly higher.

The detection rates for pregnancy loss/intrauterine fetal death, twin pregnancies, fibroids, placenta previa, breech presentation and transverse presentation were statistically similar between the two groups.

1744 pregnant women, 804 scanned images by trainees under direct supervision, 940 scanned images by trainees alone

Medical Aid Films, MaMA Mozambique and Sonosite provided financial support

Shah SP, Epino H, Bukhman G, Umulisa I, Dushimiyimana JM, Reichman A, et al. 2009 [14]

Rwanda

19 weeks +

Sonosite Micromaxx, with endocavitary probe, a curved array abdominal probe and cardiac probes

Quantitative study - no control group included. Blinded review of ultrasound scans for accuracy and quality.

Datasheets for each ultrasound scan performed during routine clinical care were collected and analyzed.

Local physician staff underwent a 9-week ultrasound training curriculum that included lectures and practical hands-on sessions.

Lecture topics included obstetrical ultrasound, cardiac ultrasound, hepato-biliary ultrasound and other advanced uses of ultrasound.

Between the participants and the ultrasound-trained emergency medicine physicians, there was 96% agreement in their interpretations of the scans.

Participants continued to use ultrasound after the training.

345 ultrasound scans

SonoSite donated ultrasound machines

Sippel S, Muruganandan K, Levine A and Shah S, 2011 [10]

Developing world

Not Applicable

Not Mentioned (Varies by Study)

Review article.

“No standardized approaches available for the length of training, curriculum for general practitioners, qualifications of trainers or mechanism of training.” (p. 4)

The length of ultrasound training ranged between 4 days and several months.

The cadres of trainees ranged from clinical officers, nurses and nurse midwives to physicians.

Trainers ranged from resident physicians, emergency physicians, radiologists, cardiologists to ultrasound-fellowship trained emergency physicians.

The curriculum and method of training varied based on the specific goals of the programs.

Overall, “a short but intensive training period is sufficient for preparing clinical officers, nurses and physicians alike to perform basic ultrasound exams” (p. 4), especially when both didactics and practical sessions are included and skills maintenance is ensured through refreshers.

Not Mentioned

Not Mentioned

Becker DM, Tafoya CA, Becker SL, Kruger GH, Tafoya MJ and Becker TK, 2016 [17]

Low- and middle-income countries

Not Applicable

Varies by Study

Systematic review.

“Short-training courses may lead to significant knowledge retention and improve practical skills, even when prior ultrasound experience was minimal.” (p. 307)

36 manuscripts included for final review

Not Mentioned

Swanson JO, Kawooya MG, Swanson DL, Hippe DS, Dungu-Matovu P and Nathan R, 2014 [35]

Uganda

10 months

GE Logiq E Ultrasound and GE Logic Book XP, with wide-band (2.0 to 5.5 MHz) convex array transducers

Quantitative – no control group included.

Expecting mothers received ultrasound exams as part of the routine antenatal care visit.

14 midwives from the study health centers underwent a 6-week ultrasound training course on limited obstetric ultrasound. 13 of which had no prior ultrasound training.

The training curriculum included “ultrasound physics, relevant anatomy and physiology, instrumentation and basic maintenance.” (p. 509)

Training methods included “lectures, small-group tutorials, audiovisual materials and supervised clinical scanning.” (p. 509)

Obstetric ultrasound provided by midwives changed the clinical diagnosis in up to 12% of the cases.

The quality assurance review of midwives’ scans diagnosing gestational number showed 100% sensitivity and specificity.

The quality assurance review of midwives’ scans diagnosing fetal presentation showed 90% sensitivity and 96% specificity.

939 patients

GE Foundation, University of Washington Radiology Health Services Research Seed Grant Program and

Seattle International Foundation supported the study.