The training of midwives to perform obstetric ultrasound scan in Africa for task shifting and extension of scope of practice: a scoping review

Introduction Ultrasound scan is one of the essential assessments that is crucial in the early identification of health risks during antenatal care. Its accessibility to women in low-and middle-income countries remains a serious challenge because ultrasound scans are not within the scope of practice for midwives. However, task shifting and extension of scope of practice aim to train midwives to assess pregnant women through an ultrasound scan. This paper aims to report the findings of a scoping review on the training of midwives to perform obstetric ultrasound scans in Africa. Methods The 6-step iterative framework for scoping reviews by Arksey and O’Malley was used to determine the extent of qualitative and quantitative evidence available on the training of midwives on obstetric ultrasound scans, which includes specifying the research question, identifying relevant studies, selecting studies, extracting and charting data, collating, summarising, and synthesising and reporting findings. Results A total of 12 articles from eight African countries were included in this scoping review. Three main themes and 13 sub-themes emerged and they are: obstetric ultrasound scan training, challenges experienced by midwives from task shifting and extension of scope of practice regarding obstetric ultrasound scan, and the value of task shifting and extension of scope of practice regarding obstetric ultrasound scan to midwives. Discussion Despite the available evidence that the training of midwives on obstetric ultrasound scans is essential to ensure the accessibility of quality antenatal health services, the training of midwives on obstetric ultrasound scans in some African countries remains a serious challenge. It is evident from this scoping review results that there is a need for African countries to incorporate obstetric ultrasound scans as part of the scope of practice of midwives. Task shifting necessitates prioritising the training of midwives on the use of obstetric ultrasound scans as one of the steps towards the achievement of the United Nations Sustainable Development Goal number 3 targets by 2030.


Introduction
Sustainable Development Goal number 3 (SDG) aims to achieve universal health coverage and access to essential healthcare services by 2030 [1].In low and middleincome countries (LMIC), progress towards achieving this goal has been a major issue despite the availability of healthcare interventions [2].Assessment of pregnant women with obstetric ultrasound scans by midwives may assist in the early identification of abnormalities, interventions and provision of appropriate treatments.An ultrasound scan is one of the health care procedures that women from LMIC do not have access to because it is mostly performed by other health care professionals (HCPs) in highly specialised areas except for midwives.Although this issue is of concern in LMIC, previous studies indicated that many women in low resource settings especially in sub-Saharan Africa will go through pregnancy without the benefit of even a single ultrasound examination [3].
In response, African countries such as Zambia, Uganda, Kenya, Tanzania, Ethiopia and Liberia have already started training nurses and midwives on the use of obstetric ultrasound scans [4][5][6][7][8].The importance of competent midwives cannot be overstated in Sub-Saharan Africa, where maternal and neonatal outcomes continue to be poor and health delivery systems are failing [9].However, the progress for training midwives on ultrasound in South Africa has been sluggish.This is contrary to the latest Guidelines for Maternity Care in South Africa [10] that states that for early diagnosis of the complications of pregnancy, all pregnant women should have access to at least one ultrasound scan between 18-20 weeks of pregnancy.This is a challenge because ordinarily, a basic obstetric ultrasound scan is only done by obstetricians and ultra-sonographers.Due to capacity constraints, the guidelines for maternity care in South Africa advocate for accredited midwives, who have undergone basic ultrasound training, to perform obstetric ultrasound scans as part of task shifting and extension of scope of practice.South African midwives have largely relied on their clinical expertise such as abdominal palpation and history taking to assess and confirm the foetal lie, foetal position, presentation, number of foetuses, foetal size; gestational age, and amniotic fluid volume.
While authorisation by the South African National Department of Health for midwives to perform obstetric ultrasound scans is encouraging, midwifery training in obstetric ultrasound scans in South Africa is extremely rare [8,9].Ultrasound training is not part of the basic and postgraduate diploma programmes in the midwifery curriculum of South Africa.Secondly, an obstetric ultrasound scan is not part of the scope of practice for midwives.Consequently, the midwives' illiteracy levels regarding the obstetric ultrasound scan may lead to difficulty in confirming the gestational age of women who are unsure of their last menstrual period, late diagnosis of multiple pregnancies and the misdiagnosis of foetal and pregnancy-related abnormalities [11].Consequently, task shifting and extension of the scope of practice for midwives regarding obstetric ultrasound scan is essential to achieving Sustainable Development Goal (SDG) target 3.7 which aims to ensure universal access to sexual and reproductive healthcare services.Nurses and midwives make up over 50% of the combined healthcare workers, hence they are central to achieving SDG 3 [2].Upskilling of midwives results in better screening, diagnosis, and management of pregnant women.The task shifting of obstetric ultrasound scans to midwives is an innovative solution that ensures an affordable and accessible point-of-care ultrasound (POCUS) [12].The World Health Organization (WHO) [13] supports task shifting and extension of the scope of practice as a strategy for strengthening and expanding the health workforce.To our knowledge, there is a minimal qualitative and quantitative evidence of a scoping review to determine the extent and availability of information on task shifting and extension of scope of practice regarding obstetric ultrasound scans to midwives in Africa.

Research method
A scoping review was used to determine the extent of the qualitative and quantitative evidence available on task shifting and extension of scope of practice regarding obstetric ultrasound scans to midwives.This evidence was then presented as a visual map.Arksey and O'Malley's 6-step iterative framework for scoping reviews was used [14].The six steps are to specify the research question; identify relevant studies; select studies; extract and chart data; collate, summarize and synthesise, and report findings.

Review question
The researchers searched the literature using two central questions which are: What is the available evidence on the training of midwives in obstetric ultrasound scans in Africa?What are the findings on the impact of task shifting and extension of scope of practice regarding obstetric ultrasound scans on midwives in Africa?

Search strategy
The literature search was conducted between September and October 2022 using PubMed, Scopus, Science Direct, EbscoHost, and CINAHL databases.Search terms included (antenatal, prenatal, prebirth, or pregnancy) AND (ultrasound or sonography or sonogram or ultrasonography) AND (midwife or midwives or midwifery) AND (Africa).The final search was limited to articles published between January 2012 and October 2022, as a preliminary search demonstrated that there were few studies published on this topic before 2012.

Eligibility criteria for inclusion of publication
Inclusion criteria included articles reporting on the training of obstetric ultrasound by midwives who work across Africa.The exclusion criteria were studies published in a non-English language, studies published before 2012, studies that evaluated the use of obstetric ultrasound scans by members of the multidisciplinary team who are not midwives, and studies that presented results from outside Africa.

Data selection and extraction
A literature search yielded 325 articles.After removing duplicates, 315 publications were evaluated.Titles and abstracts were screened for inclusion.If inclusion criteria were met, then the full text was retrieved and reviewed.A data abstraction form was developed specifically for this review, including author name, date of publication, population and setting, study aim, study design, evaluation tool, intervention comparator and key outcomes.The abstracts were screened independently by two researchers in the team.The full results were then compared for similarity and consensus.The consensuses' extracted data were entered into a Microsoft Excel spreadsheet for the organisation.The process and details of the articles included in the final analysis are presented in Fig. 1 and Table 1 respectively.Two researchers independently conducted thematic analyses on the selected publications.The key results with similar meanings were organized into themes and sub-themes.The researchers agreed on the themes and sub-themes to describe the training of midwives in Africa to perform obstetric ultrasound scans for task shifting and scope of practice expansion.

Results
Nineteen full-text articles were reviewed, and 12 articles which met the inclusion criteria were included in the scoping review.The extracted articles emanate from Kenya [3,12], Ethiopia [4], Rwanda [16], Tanzania [7], Ghana [18], Uganda [6,15,17], Liberia [8] and South Africa [19].Two studies employed the quantitative pretest, and post-test design [8,12].Four studies applied a retrospective descriptive evaluation of records such as midwives' logbooks or patient records [15,[17][18][19].Three studies followed a qualitative design [4,7,16].One study followed a mixed methods design [6].Two studies [7,16] were part of multi-national cross-country studies.  in inequity of access to ultrasound • Access to ultrasound is linked to one's financial status or subscription to medical insurance • Low-risk pregnant women are less likely to be referred for an ultrasound • Lack of training of midwives to perform obstetric ultrasound means that emergency ultrasounds could sometimes not be performed • Informal training of midwives on ultrasound makes them fearful to make clinical decisions based on their findings after the ultrasound examination • Some midwives perceive ultrasonography to not be part of their midwifery duties • Midwives with an interest in learning the skill of ultrasound ask the doctors to teach them practical skill as well as interpreting an image • Participants identified a major need for more healthcare professionals to be performing ultrasound examinations and suggested that it could become part of midwives' duties • Patients also wish to have an ultrasound done to find out about the sex of the baby to enable preparations for the baby's arrival • Ultrasound examinations were perceived as important for making decisions regarding whether the treatment of pregnancy complications was possible the patient was asked to wait for feedback from the main hospital so she could be rescanned if further imaging was required • The accuracy of the interpretation of images and all corresponding measurements in the report was 99.63% • The turnaround time from the end of the scan to the validation of the report was approximately 15 min • Patients felt that the process was safe, convenient, and reassuring • Patients had a better antenatal visit experience and increased confidence in the delivery of care • More spouses accompanied the mothers for the scans compared with those accompanying them for a routine antenatal clinic visit • All the mothers reported that the scan fostered a stronger bonding between expecting fathers and their babies Åhmana, et al. [7] 2018 Tanzania Three themes that were supported by thirteen subthemes emerged from the final analysis of the articles (scoping review) as follows: obstetric ultrasound scan training, challenges experienced by midwives resulting from task shifting and extension of scope of practice regarding obstetric ultrasound scans, and the value of task shifting and extension of scope of practice of midwives regarding obstetric ultrasound scan to midwives.

Mode of training
The literature reveals that there is no standard duration for obstetric ultrasound scan training for midwives.The training duration across different countries ranges between 1 week [8] and 3 months [19].The results of this review revealed that the training was provided to midwives by different HCPs such as radiologists, family physicians, emergency physicians and or obstetricians [4,6,11].In some instances, training programmes made use of sonographers and radiographers [15].Despite this, the results of the current review revealed that three midwives from Uganda were trained to be trainers of obstetric ultrasound scan [6].
Most of the training programmes in the current review comprised lectures, small group tutorials, audio-visual materials and supervised clinical scanning was done using face-to-face lecturer method [3,4,6,8,12,15,18].However, a study done in Kenya incorporated an e-learning module into their curriculum when providing training to midwives [11].

Curriculum content for the obstetric ultrasound scan training for midwives
There were similarities and differences in the curriculum content for obstetric ultrasound training among midwives.The most common standard curriculum for obstetric ultrasound scan training across the different countries in the current review consisted of normal anatomy, measuring foetal biometry, estimating amniotic fluid level and determination of gestational age.The curriculum also had the content to teach midwives how to detect foetal cardiac activity, foetal position, number of foetuses, placental location and diagnosis of foetal growth disorder [4,6,17,19].A study conducted in Uganda had the curriculum content to teach midwives to diagnose preterm labour, multiple gestation, oligohydramnios, placenta praevia, malpresentation and abnormal foetal heart rate using ultrasound among pregnant women in labour [17].In addition, the study conducted in Kenya had the curriculum content to teach midwives about ultrasound physics, and instrumentation [10].In Uganda, they had a curriculum content to teach midwives about the maintenance of ultrasound equipment [15].Furthermore, midwives were also equipped with the knowledge of how to diagnose complications of pregnant women in the first trimester [8].

Midwives' assessments following obstetric ultrasound training
Assessment methods included oral and practical competency tests [15].The results of the post-training assessment using ultrasound revealed that midwives from Liberia had an increased comfort level of using obstetric ultrasound.This was evaluated using the 4-point Likert scale.The confidence scales increased from 1.8 during pre-training assessment to 3.8 after post-training assessment [8].The same study demonstrated that participants' OSCE results following the training showed a significant increase and the level of knowledge was maintained even one-year post-training [8].This demonstrates that the participants continued to use the skill gained even after the training or else the results would have shown attrition after a year.

Accuracy of midwives' interpretation of basic obstetric ultrasound
A study conducted in Uganda demonstrated that midwives were able to diagnose non-cephalic presentations 100% of the time.However, the diagnosis of twin pregnancy before 32 weeks was a challenge during the training of midwives [15].It was considered that in 7.4% of the time, ultrasound enhanced midwives' clinical management of patients by correcting their initial diagnosis that they did through clinical assessment [15].A Kenyan study confirmed that midwives would scan a patient and make a follow-up with the patient postdelivery.Confirmation of findings found that the postdelivery accuracy of the scans was 97.63%.Therefore, this is an indication that midwives are capable of being taught ultrasound successfully [12] Challenges experienced by midwives resulting from task shifting and extension of scope of practice regarding obstetric ultrasound scans.

Increased workload for midwives
Midwives welcomed the use of ultrasound to promote access to healthcare services and early identification of complications, thereby facilitating timeous management.However, they also raised concerns about increased workload, resulting from task shifting and extension of the scope of practice for midwives [4].In support of this, the study findings revealed that midwives found it challenging to cope with the existing burden of workload even before task shifting and extension of the scope of practice, hence they suggested that more midwives be provided with the training to ensure a more equitable distribution of workload [12].

Patient's expectations
The midwives were unable to print the scans for the patients, the patients in turn were disappointed by this [4].Expectant mothers would also consult with the expectation of having an ultrasound performed to determine the sex of the foetus [7].Their expectations to know the sex of the baby, in cases where this is not performed voluntarily, pushed them to pretend to be experiencing the absence of foetal movement to undergo a scan.Midwives are unfortunately not trained to attend to this request as their training does not include gender identification [16].

Inaccurate ultrasound scan results
The results of this review illustrated that one midwife told the pregnant woman that the results of the scan revealed that the baby was normal.However, the baby was born with a clubbed foot [4].This finding illustrated that presenting inaccurate ultrasound scan results among pregnant women may lead to escalated litigations against midwives.

Shortage of trained midwives to perform obstetric ultrasound scans
There are a limited number of midwives performing obstetric ultrasound scans for pregnant women in these facilities.Resignations of midwives who are trained in obstetric ultrasound further adds to this [4].This shortage results in the disruption of providing health care services among pregnant women including obstetric ultrasound services.In these instances, some hospitals have relied on radiographers to perform obstetric ultrasound scans among pregnant women.It was also noted by midwives that the shortage of trained people offering ultrasound services was used by non-medically trained professionals for profit purposes resulting in the issuing of inaccurate reports to unsuspecting patients [7].This is a major concern as it could impede high-risk patients from seeking medical attention in the case that there are abnormal developments about their pregnancy.

Lack of adequate infrastructure and consumables
Studies from the current review reported that there is unavailability of private rooms to perform obstetric ultrasound scan [4] Therefore, it was difficult for them to perform obstetric ultrasound scan among pregnant women.
The other challenge was the lack of power supply which is regarded as a barrier to providing health care service [4] among patients.Another study reported concern in the lack of consumables to perform obstetric ultrasound scan among pregnant women, such as ultrasound gel, memory sticks, referral forms among others [4].

Improved access to antenatal care
The task shifting and extension of the scope of practice regarding obstetric ultrasound scan to midwives increases access to obstetric ultrasound during pregnancy.This was evidenced by a study done in South Africa which demonstrated that 97% of pregnant women in a particular primary health care facility had received an ultrasound scan during pregnancy and this enhanced the utilization of antenatal care [19].As regards, increased access to ultrasound, there was a 3% increase in overall referrals based on the ultrasounds which were carried out by the midwives [19].The other study conducted in Uganda to triage patients reporting labour increased the likeliness of referral for high-risk conditions.This therefore increased the burden of false positives reporting to an already overburdened higher level of care [17].

Improved maternal outcomes
The reviewed literature demonstrated that obstetric ultrasound scans improved perinatal outcomes in pregnant women.Midwives considered ultrasound to be a life-saving diagnostic tool, especially for obstetric emergencies such as antepartum haemorrhage [7] because they were able to refer them to a higher level of care timeously.

Improved neonatal outcomes
Midwives saw ultrasound training as a key intervention in decreasing maternal and neonatal mortality as they were able to diagnose the location of pregnancy and the lie of the foetus, determine foetal well-being, assess the placental position, and detect gross foetal abnormalities [4,7].The assessment of the cervical length through obstetric ultrasound was also seen as an important predictor of preterm labour [18].Therefore, this practice enabled them to plan whether or not to administer corticosteroids for lung maturity to the foetus [16].One of the most striking results to emerge from the data was that obstetric ultrasound scan training equipped the midwives to identify congenital abnormalities that are more visible on ultrasound such as gastroschisis, hydrocephalus and spinal bifida [18].

Midwives' readiness and willingness to learn the performance of obstetric ultrasound scan
Midwives advocated for obstetric ultrasound scan to be part of their routine duties [16].Another study reported that the basic obstetric ultrasound programme results in increased confidence in midwives [4].Despite this, some of the midwives expressed that obstetric ultrasound scan was the duty of a physician and expressed discomfort in performing obstetric ultrasound citing safety concerns for the foetus [16].

Discussion
This scoping review focused on 12 studies.The studies found in this review were conducted across 8 African countries which are Kenya [3,12], Ethiopia [4], Rwanda [16], Tanzania [7], Ghana [18], Uganda [6,15,17], Liberia [8] and South Africa [19].These studies were also conducted from three different levels of care which are primary [6,15,17,19], district [6,7,11] and tertiary [7,8,11,18].The current scoping review demonstrates that countries across Africa are making efforts to train midwives on how to perform obstetric ultrasound scans.The efforts of training midwives in these countries form part of the cumulative strategies of improving access to maternal health care services of pregnant women in African countries.
The results of the current review illustrate that there is no specific duration for providing obstetric ultrasound scan training in different countries.However, the longest training of obstetric ultrasound scans for midwives was 3 months [19].In these training midwives were taught how to perform basic scans to determine basic information such as gestational age [6,18,19], identify obvious congenital abnormalities on ultrasound [6,18] and identify high-risk features of pregnancy on ultrasound [6,19].In contrast midwives who were trained to be on ultrasound scanning for pregnant women maybe regarded as train the trainers while waiting for the development of the curriculum that maybe used to train midwives of ultrasound.Training the trainers may positively assist in boosting their confidence levels further.The purpose of training these midwives was to make sure that they provide continuous mentorship to the midwives who were part of the study cohort.Therefore, this necessitated the need for developing a curriculum that maybe used to train midwives on ultrasound in Africa.However, the competencies for the development of the curriculum and extension of the scope of practice must be regulated by nursing councils regulating the curriculum for midwives based on the competencies that needs of a specific country.
There were both negative and positive impacts on task shifting and extension of the scope of practice regarding obstetric ultrasound scans to midwives.On the negative impact of task shifting and extension of scope of practice regarding obstetric ultrasound scan, midwives stated that performing obstetric ultrasound negatively impacts their workload [4] and they have a low number of trained midwives in ultrasonography [16].Provision of inaccurate ultrasound scan results to patients, was also identified as a negative factor.The literature review is silent on inaccuracy of results to pregnant women by other health care professionals after performing ultrasound scan.It is therefore important for midwives to explain to pregnant women that they are using a basic scan with limited information to rule out all foetal abnormalities, before the commencement of the procedure.Inadequate infrastructure was also pointed out as a barrier to performance of obstetric ultrasound scans.Interruption of power supply and lack of ultrasound equipment also proved to be a stumbling block for offering obstetric ultrasound scan [4].However, it might be useful to consider such backup alternatives as generators to avoid interruption of healthcare services.These challenges must be addressed because they have the potential for interrupting the provision of maternal healthcare services and for promoting access to healthcare services.Despite this, there was a positive impact of task shifting and extension of scope of practice regarding the training of obstetric ultrasound to midwives.Midwives indicated that the obstetric ultrasound scan assists them to identify the risks and complications associated with the women's pregnancy timeously.Consequently, early referrals of women experiencing pregnancy complications can be done hence reducing maternal and neonatal mortality rates.The findings of this scoping review were consistent with a narrative review on the use of obstetric ultrasound in African countries [20] and another narrative review on achieving universal access to obstetric ultrasound in African countries [21].Based on the findings of this scoping review, there is a need to empower and train every midwife on how to use obstetric ultrasound in African countries.This can reduce the existing workload among midwives that are already trained.Also, there is a need to incorporate obstetric ultrasound training in both the undergraduate and postgraduate curricula of midwifery training in African countries.In-service training must be done for the midwives that are already in practice to expedite the task shifting and extension of scope of practice regarding obstetric ultrasound training to midwives as they are the first contact and primary caregivers for pregnant women across all levels of care in African countries.
The limitation of this review is that the literature only included studies which were conducted in African countries, therefore, the researchers are unable to generalise the results.Future research should focus on engaging the nursing regulatory bodies in African countries to include obstetric ultrasound as a competency in midwifery curricula.

Conclusion
Access to obstetric ultrasound training for women in African countries necessitates task shifting and extension of scope of practice to enable midwives to be trained in large numbers on the use of obstetric ultrasound.Training midwives on the use of obstetric ultrasound scans are essential in Africa to ensure universal access to obstetric ultrasound.Midwives that are trained must be used as mentors to teach their colleagues on how to perform obstetric ultrasound scans when caring for pregnant women.More African countries need to be cautious about training a maximum number of midwives to ensure the sustainability of ultrasound service when it is finally rolled out.Each healthcare facility must have a backup plan for power cuts to avoid interrupting services needed by pregnant women.Nurse managers must budget and purchase consumables needed to conduct obstetric ultrasound scans.Ultrasound services can promote successful task shifting and extension of scope of practice regarding obstetric ultrasound scans to midwives in Africa.

Glossary
Task shifting is a global recommendation from World Health Organization that involves the coherent redistribution of tasks to individuals within the healthcare team with fewer qualifications that conventionally were not within their scope of work [22].

Extension of scope of practice
The South African Nursing Council (SANC) defines scope of practice of a Nurse or Midwife as the" knowledge, practices and attitudes required to fulfil a professional role" [23].Scopes of Practice can be used as a reference when writing standards for educational programmes and to provide guidelines for workers.It usually does not include a complete list of what a professional is allowed to do.Saxon, Gray & Oprescu [24]add that extended or expanding scope of practice is operationalised as permitting healthcare workers additional roles to improve patient access to timely health care through accessing specialized training outside the traditional scope of their discipline.Obstetric ultrasound scan it is a non-invasive imaging, and accurate method to clinically evaluate and confirm if a woman's pregnancy is viable and the fetus is growing in intrauterine environment throughout the woman's pregnancy and confirm gestational age [25]

Table 1
Summary of articles included in the

Table 1 (continued) Author, date Population and setting Study aim Study design, evaluation tool Intervention comparator Key outcomes
[16]lund, et al.[16]2017 Rwanda Midwives n = 23, all female age range: