Characteristics of the study participants
We conducted a total of ten FGDs, three with 19 community members and seven with 39 MNC providers. Additionally, we conducted 52 IDIs, 23 with health facility managers, six with recent mothers who have had a live birth within three months before the interview, and 23 with MNC service providers. All the recent mothers who participated in the FGD were married, 22-30 years old, about half of them attended above secondary school, about three-fourth of them had unskilled manual work as an occupation, and most of them had between two-three children. The MNC providers who participated in the FGD were 20-37 years old.
Enablers and barriers of introducing obstetrics ultrasound
Analysis of the IDIs and FGDs identified two major themes and 12 sub-themes related to enablers and barriers of introducing obstetrics ultrasound. The major themes identified were health system and client-related factors (Fig. 1).
Health system-related enablers
Improved health workers knowledge and skills
MNC providers reported that the training provided to them on Vscan ultrasound as part of the introduction of the technology in their facilities built their knowledge and skill. They felt that the knowledge and skills they gained improved their confidence and helped them to better diagnose obstetric complications.
"We received an ultrasound machine and training on how to use it. The training helps me in early identification of maternal and fetal complications. It makes me confident about what action to take in any situation." (MCH case team leader)
Increased health workers and clients’ motivation
The health service managers noted that MNC providers were motivated and interested in providing the ultrasound examination for pregnant women because they were able to diagnose complications and take recommended action. It also attracted the community and created an opportunity to improve uptake of other health services provided by the health facilities. The maternal and newborn service provider asserted that the availability of the ultrasound service makes mothers happy and improves their interest to show up at their next scheduled ANC visit.
“Availability of ultrasound scan is another reason for the increase of ANC uptake. Pregnant mothers who received the ultrasound service discuss the service with other pregnant mothers and then motivate them to come to this health center." (MCH case team leader)
The MNC providers believe that the introductions of the Vscan ultrasound service at the health center level makes the service accessible to pregnant women and motivated them to come to the health facility to use the ANC service. According to the MNC provider, hearing their fetal heartbeat through the ultrasound machine increases the pregnant women’s satisfaction with their service and their trust in the MNC providers.
"(The number of) ANC users increased from time to time, especially after the introduction of ultrasound. (FGD, MNC provider at a hospital)
Increased maternal and newborn service utilization
The training on the ultrasound technology, the supportive supervision, and the Vscan Access ultrasound machine contributed to improved maternal and newborn service uptake in their health facilities. Some of the MNC providers think that the health facilities’ ultrasound service was the primary reason for increased delivery service uptake they observed.
"When ultrasound service was not available, we used to send mothers to hospital for further diagnosis, but now this problem is solved. The ultrasound service (in our facility) increased the annual number of deliveries to about 300, from less than a hundred in the previous year". (Maternal newborn service provider)
The dissemination of information about the availability of the service played a great role; mothers who didn’t use ANC service previously were motivated to use the service when they heard about the ultrasound service availability.
Improved quality of MNC
The participants believe that the availability of Vscan Access ultrasound at the primary health care level has highly contributed to improved quality of the MNC care they provide and their confidence in the service they provide and receive.
"The presence of ultrasound increased our service quality and increased the interest of mothers to come to our health center to get the service." (Health center manager)
"There were different materials added to the facility that improved the quality of the service (the health center provides), for example, (the) ultrasound." (Mother who recently give birth at the health center)
Improved referral system of the facility
Furthermore, the study participants reported that the Vscan Access ultrasound service improved the referral management at the health centers and primary hospitals because they were able to identify complications, make correct diagnosis, take the right decisions, and make the appropriate referral decision at the right time.
“The (Vscan Access) ultrasound at our health center helped us to make correct diagnoses and referrals. (MNC provider at health center)
“The availability of equipment like ultrasound contributes much more to (improved) referral management.” (Health center manager)
In addition, the Vscan Access ultrasound service helped MNC providers to avoid unnecessary referrals of pregnant women to higher level health facilities. Using the ultrasound machine, they were able to identify mothers who can or can’t deliver at the health center and need a timely referral to a higher level.
"The Vscan Access the ultrasound reduces the referral of mothers (to higher level facilities) because we could manage different complication using the ultrasound." (MNC provider)
Health system-related barriers
Vscan access ultrasound related barriers
Interruption of the ultrasound service was a common challenge MNC providers frequently reported. According to the MNC providers, the ultrasound breakage is a major reason for discontinuity of the ultrasound service in their facilities. The maintenance of the ultrasound machine is done outside the health facility and takes long time, resulting in interruption of the service.
"We used to have one (Vscan) ultrasound machine, but it is not functional now. We use a fetoscope to detect the fetal heartbeat, and the finding might differ from one midwife to the other. We might refer a mother for fetal distress because of poor diagnosis (with the fetoscope)." (Health center manager)
In addition to machine breakage, another reason for the ultrasound service interruption study participants mentioned was the shortage of jell.
"Sometimes we run out of jell for the ultrasound scan. During those times, we send clients to the nearby private or public hospital for an ultrasound scan." (MCH case team leader)
In addition, shortage of electric power supply was discussed as an important barrier limiting the continuous provision of ultrasound scan services. Although some of the facilities have solar energy panels as an alternative energy source, they are not sufficient to accommodate the energy needs of different equipment the health facilities have.
Shortage of staff and high workload in the facility
Despite MNC providers’ interest in the Vscan ultrasound and their motivation to provide the service, their limited number affected the provision of the service to pregnant women. Availability of only one or two midwives per health center and few more at primary hospitals to manage all maternal and newborn health service mean they have high workload and do not prioritize provision of the ultrasound scan service, which is considered as additional care.
"Shortage of human resources for maternal and newborn care is also another challenge we face in this health center. (The) only midwife (at our health center) provides family planning services, childbirth care service, antenatal care, and ultrasound examination everyday day……..." (MNC provider at health center)
"The ultrasound service is being given twice a week Tuesday and Friday after 8:00 o’clock local time (2:00pm)… We restricted the service to only two days per week because of the shortage of staff." (Health center manager)
In addition to the shortage of midwives at the health center level, lack of access to training on Vscan Access ultrasound limited the service provision. Although the program trained two midwives from each facility on obstetrics ultrasound, some trained staff were transferred to other facilities without replacement, may not come to work due to social problems, maternity leave, or other reasons. As a result, the ultrasound service could not be routinely provided to the pregnant mothers.
"We trained two staff (members) on antenatal (Vscan Access) ultrasound. One of them has left our health center. Sometimes, due to social or health problems, if she (the remaining staff) couldn't come, we can't provide the service. Rather, we appoint the pregnant mothers again and again for the ultrasound scan." (Health center manager)
Low competence of the MNH providers
Limited capacity of the MNC care providers to provide the ultrasound scan was another barrier identified as a reason for poor performance of the ultrasound service provision. Some of the MNC providers stated that they received short training (ten days) without enough clinical practice, which left them with limited capacity to diagnose obstetric complication and low confidence to make a clinical decision, particularly on the first-trimester ultrasound scan.
"The ultrasound training given to midwives is just a highlight. It is better if they are well-trained." (Health center manager)
They feel that they have a skill gap to provide the service independently, and some of them believe that radiologists should provide the service. Despite the availability of providers trained on ultrasound scans in some health facilities, they continue to refer pregnant mothers to a private or public hospital for an ultrasound scan.
"As to me, the availability of the ultrasound machine at health center level does not reduce the referral out due to the fear of death (maternal or neonatal), which means still they (the MNC providers) have a capacity gap." (MNC provider)
Client related enablers
Availability of free of charge ultrasound service
The provision of the ultrasound service free of charge was one of the important enabling factors that motivated the mothers to use the service. However, not all health centers provide the ultrasound services free of charge.
"Last time I came across IUFD, and I have used the ultrasound to confirm and refer her to the hospital. The availability of ultrasound service free of charge saved the mother from the cost she would incur for the ultrasound (scan). When working in the ANC room, I used to give an ultrasound scan three times a week for five mothers per day. The (free) ultrasound service is vital for mothers who can't afford to pay for the service." (MNC provider)
High demand for the ultrasound service
In general, pregnant women want more ultrasound examination than they received. Pregnant women showed a high interest in the ultrasound scan.
"(All) mothers who visited our health center for antenatal care ask for the ultrasound service." (Health center manager)
The provision of the ultrasound service at the primary care level increased mothers’ satisfaction and trust in the health care providers. Hearing fetal heartbeats and observing the fetal movement in the womb during the scan makes the mother happy and interested to show up at their scheduled ANC visits
"Some mothers come, and they say 'I feel some pain, please examine me using the 'machine,' by machine they meant the ultrasound." (MNC provider)
Client related barriers
Maternal perceptions and concerns
Pregnant women who visit health facilities show a keen interest in ultrasound scans. They think that they should have the ultrasound scan for each complaint and during all of their ANC follow-up visits. They also feel that other examinations provided during the routine ANC follow up are not as important as the ultrasound scan.
"They haven't sent me to other hospitals to be seen by a computer (ultrasound) because they said I have no problem. I haven't taken the computer examination on my own either, since they didn’t prescribe the scan to me." (A lactating mother who recently give birth at a health center)
Mothers feel that health care providers discriminately provide the ultrasound scan to some pregnant women. Even if the ultrasound service exists in the health facility, they feel, providers don’t provide the service consistently to all mothers. They feel that the health providers selectively provide the ultrasound scan to the mothers they know or their relatives.
"In case of the ultrasound, I think they selectively provide the service to the mothers they know. Otherwise, they will not (provide the service)." (Health development army, FGD participant)
Perceived limited knowledge and skills of providers and small size of the ultrasound machine
The satisfaction of mothers with and trust in the ultrasound scan they received at the health center by the trained mid-level provider affects their use of the ultrasound service. Some mothers have doubts about mid-level healthcare providers’ knowledge and skill in providing the ultrasound service.
"They checked me with ultrasound and said the baby is fine. And, they gave me medicine, but I couldn't get better; rather, I felt worse. Then I went to "X" private hospital for another ultrasound examination because I doubted (the scan I received at) the health center." (Lactating mother who recently give birth at the health center)
Besides the providers’ capacity, the mothers also doubt the quality of the ultrasound machine used at the health center. They think that the size of the Vscan Access ultrasound machine used at the health center was very small. For the mothers, the small size ultrasound might not show anything about the fetus and the mother’s health condition. Even if some health centers provide the ultrasound examination for free, because of the size of the machine, some mothers prefer the ultrasound scans at private facilities.
"The ultrasound (machine) is very small; the screen is like the size of my cell phone, and I don't think what they see through that screen enables them to know about anything. There is normal ultrasound in other facilities; with that ultrasound, you can see things very well as if you are watching television and the doctors interpret things for you. That way, you feel satisfied. But, the ultrasound in the health center, I don't think that is big enough to see something even for health workers. (Mother who recently give birth at the health center)