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Table 2 Potential entry points for improving gestational age estimation

From: “I can guess the month … but beyond that, I can’t tell” an exploratory qualitative study of health care provider perspectives on gestational age estimation in Rajasthan, India

Level

Potential intervention points to improve gestational age estimation, documentation, and use

Health system

• Clarify protocols and expectations on which gestational age estimation methods to use and when, how to navigate conflicting estimates, and how to document and use gestational age

• Increase health system focus on the risks of preterm birth, and the importance of identifying preterm births quickly in order to provide supportive interventions

• Build health system capacity to use gestational age estimates for clinical decision making, to ensure that gestational age accuracy is a meaningful part of antenatal and intrapartum care provision (i.e., ensure that interventions are actually available to address problems identified through gestational age estimation)

Ongoing quality improvement: Train, support, and supervise health workers on gestational age estimation, including training that compares provider estimates to a gold standard and offers feedback

• Reduce provider workload so that they have sufficient time to assess and document gestational age during ANC

• Increase the accessibility of equipment that aids gestational age estimation, particularly ultrasound but also measuring tapes for fundal height assessment and gestational age wheels

Frontline health care provider characteristics

• Improve providers’ technical understanding of gestational age estimation methods, including the inherent limitations of each method and the standardized protocols (such as ACOG [19]) for resolving discrepancies between LMP and ultrasound dating

• Improve providers’ capacity to correctly estimate gestational age, including on how to work with women to get a best-possible last menstrual period date when possible, clarifying that estimation is from the first day of the last menstrual period, training on how to use a measuring tape to assess fundal height and knowing the time period within which ultrasound dating is accurate

• Enable providers to build rapport and trust with clients and communities to encourage timely care-seeking and open discussion of menstruation and sexual activity

• Providers will value gestational age estimates and be willing to invest time and energy into improving their accuracy and documentation when they know that gestational age estimates are important to client health

• Provide respectful and high-quality maternal healthcare to increase the value of early and regular ANC for women

Patient characteristics

• Encourage women to seek first ANC as early as possible through outreach, awareness raising, and incentives since this will improve LMP recall for those with regular menstruation prior to pregnancy and will enable early ultrasound when gestational age estimation is most accurate

• Build health system capacity to communicate effectively across language groups and among migrants through translation, appropriate within-community outreach efforts, and recruiting and training health care providers from linguistically diverse communities

• Increase family support for early ANC and ultrasound by reducing financial and geographical barriers to access and communicating the value of accurate gestational age estimates

• In addition to broadly increasing women’s access to education, engage lower-literacy women through audio visual media, community outreach and social groups to build understanding of menstruation and maternal healthcare

• Equip frontline health care providers with strategies to interpret dates reported by women with different cognitive approaches to time, such as by linking harvests and festivals to the Gregorian calendar

Gestational age estimation method

• Interventions to improve gestational age accuracy must account for the inherent limitations in terms of their accuracy and the stage in pregnancy when they can be used

Ease of use and equipment required must be considered when considering strategies to improve gestational age estimation