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Abstract
Objective The purpose of this exploratory study was to assess healthcare providers’ perspectives on maternity care following the introduction of ultrasound services in the area.
Design The qualitative descriptive study.
Study setting This study was carried out in health centres under Child Health and Mortality Prevention Surveillance (CHAMPS) pregnancy surveillance catchment areas in Kersa, Haramaya and Harar districts in eastern Ethiopia.
Participants The study participants were 14 midwives working in the maternity units and 14 health centre managers in the respective health facilities. Purposive sampling was used to select participants for in-depth interviews using a semistructured interview guide. Data were analysed using thematic analysis.
Results We identified one overarching theme "improved perinatal care" and six subthemes. Based on the accounts of the participants, the introduction of ultrasound services has led to a remarkable transformation in the overall provision of maternity care at health centres. The participants have reported a substantial rise in the utilisation of antenatal, delivery and postnatal care services. The availability of ultrasound has enabled midwives to deliver comprehensive maternity care.
Conclusion Ultrasound service utilisation at health centres improves maternity care. The utilisation of ultrasound in healthcare enables providers to closely monitor the growth and development of the fetus, identify potential complications or abnormalities and administer timely interventions. This integration of ultrasound technology translates into enhanced prenatal care, early detection of issues and prompt management, ultimately leading to improved outcomes for both the mother and the baby.
- obstetrics
- maternal medicine
- patient satisfaction
- primary health care
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and Limitation fo the Study
The study focuses on practical evidence occurring in the health centre.
Health professionals at the health centres provide information based on their first-hand knowledge and experiences.
In this report, we included the views of heath care providers not the users of this service.
Though there are external validity issues, the result can be transferable to other similar contexts.
During translation to English from local languages, the actual meanings of words might have been misplaced.
Introduction
Maternal survival has been a crucial focus in global health, including Ethiopia. Sustainable Development Goal 3.1 plans to reduce maternal mortality to less than 70 deaths per 100 000 live births by 2030.1 2 Unfortunately, In Ethiopia, maternal mortality remains high, 1 in 267 women die of pregnancy-related causes.3 This is primarily due to delays in receiving adequate care and a lack of quality maternity services. A study conducted in Ethiopia revealed that the third delay, which refers to the delay in receiving appropriate care at the health facility accounted for 36.3% of maternal deaths.4 5 One of the reasons for this delay is the limited ability of health centres to diagnose maternal problems early during antenatal care (ANC). This is mainly attributed to a lack of advanced technology and well-trained healthcare professionals.6
According to the WHO, ultrasound examinations in early pregnancy play a crucial role in reducing pregnancy-related complications and are recommended as part of routine ANC.7 Ultrasound examinations help detect fetal conditions such as heart rate, position, presentation, gestational age and abnormalities.7 This enables early referral to hospitals, preventing life-threatening complications. A study conducted at 25 health centres in Ethiopia demonstrated that the introduction of obstetric ultrasound scanning services at health centres contributed to the prevention of 1970 maternal morbidities and mortalities per 100 000 live births. Similarly, a study from Uganda suggested that the availability of a low-cost antenatal ultrasound programme could help lower maternal mortality by encouraging women in rural areas to seek skilled ANC and delivery assistance at a hospital.8
Maternal mortality rate in urban Ethiopia is significantly lower than in rural areas due to early detection and treatment of pregnancy-related problems during ANC.9 Women in rural areas experience preventable morbidities and mortality, primarily because of the limited chance of identifying complications during pregnancy.10 Prenatal ultrasound examinations are virtually non-existent in rural Ethiopia, making women in these areas six times less likely to use prenatal ultrasound.11
Ethiopia has a limited number of radiologists (approximately 95) and, gynaecologists and obstetricians (462), with the majority of them concentrated in the urban areas and the capital city.6 While the majority of ANC and delivery service attendants are in rural primary healthcare units. When ultrasound service is required, women in rural areas are referred to hospitals or private healthcare facilities in urban areas, resulting in longer travel times, additional costs and discomfort for the referred women.6
A well-trained midwive could play a significant role in preventing maternal and newborn deaths, as they could provide (87%) of all necessary sexual, reproductive, maternal and newborn health services.12 However, due to a lack of training and appropriate technology including basic ultrasound, midwives in Ethiopia are unable to effectively address maternal and neonatal morbidity and mortality.
Child Health and Mortality Prevention Surveillance (CHAMPS) pregnancy surveillance has been implemented in 21 health facilities in Harar, Kersa and Haramaya districts in eastern Ethiopia. This programme includes the use of ultrasound and haemoglobin level measurement as point-of-care tools. Midwives receive training from gynaecologists to determine gestational age and monitor the baby’s growth and development at a Hiwot Fana Comprehensive Specialised Hospital. The main aim of this exploratory study is to explore the perspective of healthcare providers regarding the use of ultrasound and its benefits for maternal healthcare in these respective health facilities
Methods
This report is based on the Standards for Reporting Qualitative Research framework depicting study context, findings, analysis and interpretations.
Qualitative approach and research paradigm (study design)
A qualitative descriptive method applied to understand the perspectives of healthcare providers on the improvement of maternity care following the introduction of ultrasound at the health centres and its contribution to the improvement of maternity care.
Research characteristics and reflexivity
The research team consisted of Ethiopian public health experts and midwives who held at least an MSc degree. The interviews and analysis were conducted by experienced senior researchers who previous experience in conducting a qualitative study. The interviews were transcribed and translated by experienced MSc nurses who were not involved in the study’s design. The data analysis and interpretation were carried out by high level experts in the area and also involved in the study’s design.
Before the study began, there was no prior interaction between the researcher and the participants. However, the researchers were familiar with the culture and norms of the area, as they were native speakers of the local languages, Afan Oromo and Amharic. This helped to minimise any potential power imbalance between interviewers and participants. Furthermore, the participants had never met any of the researchers. It is important to note that all participants were informed that the interviews would be recorded for research purposes.
Context/setting
This qualitative descriptive study was carried out at 14 rural health centres in eastern Ethiopia, specifically in the Harar, Kersa and Haramaya districts where the CHAMPS is working in the Health and Demographic Surveillance Sites (HDSS) catchment areas, from February to April 2022. The implementation of ultrasound services in these health centres is relatively recent and not widely available in other health centres in the area. The HDSS catchment areas include a total of 21 health facilities, consisting of 18 health centres, 1 specialised hospital and 2 general hospitals. However, this study focuses on the 14 rural health centres.
The CHAMPS pregnancy surveillance
The CHAMPS pregnancy surveillance assigned midwives at each health centre, who had received ultrasound training as part of the CHAMPS Ethiopia programme. The training primarily focused on determining gestational age, which is challenging to know last menstrual period to calculate gestational age among rural women. Additionally, it provided insights into detecting complications during pregnancy and monitoring fetomaternal outcomes. The training aimed to equip midwives with skills in operating ultrasound machines, conducting ultrasound imaging and interpreting the results. The midwives had no prior experience in ultrasound scanning, reading or interpretation. Senior obstetricians and gynaecologists from referral hospitals in the area conducted the training, and the midwives were provided with manuals. Following the theoretical training, they underwent a 1-month practical attachment at the hospital, supervised by senior obstetricians and obstetric residents. Each midwife was expected to perform 10 supervised ultrasound examinations per day. If any abnormal or unclear findings were detected, immediate consultation with the senior residents was required. The coordinator assessed their overall activity and performance daily, providing professional explanations and suggestions for any unclarified findings.
Post-training scanning skill competency was evaluated by senior residents using a structured competency checklist. Participants were expected to score 80% and above to demonstrate competency, if the required minimum score was not achieved, participants had to repeat the practice for 1 week and be reassessed until they reached the required level of competency. The evaluation included various aspects such as preparing women for an ultrasound of pregnant operation the ultrasound machine, conducting ultrasound imaging, and interpreting normal and abnormal findings. The trainers were also assessed on their ability to identify the uterus, adnexa, gestational sac, yolk sac and fetal cardiac activity. Additionally, they were expected to calculate measurements such as mean sac diameter and crown-rump length during the first trimester. In the second and third trimesters, they were expected to evaluate the placenta, measure cervical length and amniotic fluid amount, determine the number and position of fetuses, and accurately estimate biparietal diameter, head circumstance, abdominal circumference and femur length. After completing the training, they were assigned to 17 health centres. The follow-up was done for one to 2 weeks to confirm the competency of the trainee until they can perform an ultrasound examination independently. This study was conducted 6 months after the introduction of ultrasound as pregnancy surveillance activities at health centres.
Sampling strategy
In this study, we used purposive sampling to select participants. The participants consisted of midwives involved in providing maternity care and health centre managers from selected health centres in Ethiopia. Specifically, we included health centre managers and midwives working in rural health centres located in the Kersa, Haramaya and Harar areas. However, we excluded midwives who work in areas other than the maternity unit, as well as those who perform ultrasound. The rationale behind excluding the ultrasound-performing midwives was that their responsibilities did not directly involve ANC. Instead, they were specifically recruited to collect pregnancy surveillance data.
Data collection instruments and method
Trained facilitators conducted in-depth interviews while simultaneously recording the conversations and taking notes. These interviews were guided by a semistructured interview guide, which was developed through a review of relevant articles13 14 and consulting with professionals. Following a pretest at Haramaya General Hospital, an edited version of the guide was used for the subsequent in-depth interview, to ensure a continuous iteration process.
Units of study
In total, we conducted interviews with 14 midwives working in the maternity unit, along with 14 health centre managers. It is important to note that we conducted more interviews than the typically recommended minimum of 12 interviews to ensure that we achieved topic saturation15
Data processing and analysis
The audio recordings from the interviews were transcribed verbatim in both Afan Oromo and Amharic languages. During the analysis process, these transcripts were translated into English. Thematic analysis, a method commonly used by postpositivists, was employed as the analytical approach,16 Postpositivists use thematic analysis to gain insights into external reality by focusing on individuals’ meanings and experiences.17 The generation of the theme was with an inductive approach, starting with the raw data. In the initial phase, the transcripts were read multiple times to develop familiarity with the subject matter. The meaning unit was then identified involving the identification of the statements that aligned to the purpose. In the subsequent step, condensation took place, preserving fundamental meaning while reducing the length of the units. The condensed meaning units were then grouped and coded. Codes containing similar information were organised into categories, and these categories were further grouped into themes. Throughout the research process, the research group engaged in an open and critical dialogue. This dialogue continued until the final terms were determined, allowing for the exploration of alternative descriptions and interpretations
Techniques to enhance trustworthiness
Throughout the process, five methods were employed to maintain the trustworthiness of the data First, after conducting the interview, the interviewer summarised the participants’ responses to enhance the credibility of the data, which was then approved by experts for accuracy. Second, the researcher and senior researchers engaged in peer debriefing to evaluate the credibility of the findings. Third, during data collection, the interviewer used the same interview guide for each participant to probe and gather consistent information. Fourth, any unusual reactions from the participants were noted to ensure dependability. Lastly, the researchers thoroughly reviewed the objectives, methods and procedures to improve the rigour of the findings. Additionally, to ensure consistency, were consistent, the complete transcription was compared with the audio recordings.
To achieve a high level of validity and quality in the data, several methods were employed. The importance of confidentiality was emphasised to create a safe and comfortable environment for participants to openly share intimate details and provide comprehensive descriptions of their experiences. Moreover, transferability was also ensured by using a purposive sampling method to obtain information-rich participants, and the researcher attempted to obtain in-depth information during the interview.
Patient and public involvement
There was no patient or public involvement.
Results
A total of 28 individuals were included as participants in the study, the majority of the participants (80%), had BSc degrees. 75 of the participants were in the age range of 20–30 years ago and 89% of them had more than 5 years of experience (table 1).
Sociodemographic of study participants
In this study, a main theme and six categories were identified. The overarching theme of the study was, ‘improved perinatal’, under which six distinct categories were determined. These categories include ultrasound increasing utilisation of maternity care, reducing delays at healthcare facilities, creating trustworthy work and a sense of fulfilment, reducing devastating conditions, community acceptance and expansion of the ultrasound services
Improved perinatal care
Improved perinatal care refers to the enhanced medical support and interventions provided to both the mother and the baby during the period surrounding childbirth. ANC plays a crucial role in promoting the health and well-being of the mother and the developing fetus. With the utilisation of ultrasound technology, ANC has seen significant improvements.
Ultrasound increases the utilisation of maternity care
According to the participants’ accounts, the introduction of ultrasound service has brought about a significant transformation in the overall provision of maternity care at the health centres. The participants reported a substantial increase in the utilisation of antenatal, delivery and postnatal care. Despite ongoing efforts to mobilise the community, the uptake of maternity care services has remained low at the health centres. However, with the introduction of ultrasound services, there has been a more than twofold increase in the utilisation of maternity care services.
Furthermore, the availability of ultrasound services has had a positive impact on women who have experienced abortion. Historically, abortion has been a sensitive topic, often concealed by women. However, since the introduction of ultrasound services, women with a history of abortion have also sought maternity care at healthcare facilities. The ultrasound service has facilitated midwives in providing timely and high-quality ANC. It has enabled accurate diagnosis and appropriate management of the condition. Additionally, ultrasound is also used during labour in cases where there are double concerns, thereby improving the likelihood of institutional deliveries.
One participant shared their observation of change in ANC at their health centre at their health centre before and after the introduction of ultrasound services.
HC1 …before the implementation of ultrasound service, the first ANC visit was good, but the second to fourth visits were almost non-existent, indicating a lack of follow-up and engagement from pregnant women during that period. However, after the ultrasound service was introduced, there was a significant improvement in, the provision of ANC service during the second to the fourth visits. The availability of ultrasound scanning has played a crucial role in enhancing the quality of ANC. Because the utilization ultrasound has provided relatively accurate findings, which in turn has supported effective management and decision-making in ANC services.
HC3 As mentioned previously, there have been significant transformations in maternity care, one notable change is the increasing number of women seeking antenatal services since the introduction of ultrasound service in our health center. This improvement has had a positive impact on our delivery service as well. Despite CHAMPS having its catchment area, the midwives are providing care to all pregnant women, including assessing the completeness of abortions. We have observed a significant increase in the number of women who have sought our services during the postnatal period. We are proud to report that we have made notable advancements in both the quantity of women we serve and the quality of care we provide.
One participant stated the ultrasound increased the quality of care
HC1 Ultrasound plays a crucial role in the management of maternal and fetal health as it enables us to detect abnormalities such as hydrocephaly, oligohydramnios, and placental position at an early stage. This, allows us to make informed decisions regarding early management strategies. Additionally, the use of ultrasound has significantly improved the coverage and quality of ANC. Previously, GA estimation relied on fundal measurement, which varies depending on the person measuring it. However, with the introduction of ultrasound, we can confirm the estimated gestational age, as well as fetal presentation. This has instilled greater confidence in ANC and has contributed to an overall higher quality care.
Ultrasound reduces delays at the healthcare facilities
The majority of women who receive ANC now have access to ultrasound services. In a case where any issues or concerns are identified during ultrasound examination, the midwives conducting the ultrasounds collaborate with colleagues in the maternity unit. Together, they promptly refer the women immediately to the hospital for further evaluation and treatment. Additionally, they established a connection between the women and the midwives working in the hospitals through phone calls as part of the pregnancy surveillance study. This ensures a women receive timely and appropriate care at the hospitals, promoting early intervention and improved outcomes.
One participant discusses the importance of ultrasound in the early detection and management of problems.
HC4 Before the introduction of ultrasound in our health center, it was challenging to identify abnormalities in the fetus. Women carrying conditions like anencephaly would continue their pregnancies without being aware of the conditions. However, with the availability of ultrasound, we can now detect such anomalies at an early stage. This enables us to promptly refer women to hospitals where they can receive specialized medical attention. Additionally, other complications, such as abnormal placental position and oligohydramnios, are detected early through ultrasound, leading to timely referral and early management at the hospital. Consequently, the implementation of ultrasound has significantly reduced the occurrence of unexpected negative outcomes in later stages. I strongly believe that ultrasound has had a profound impact on the early management of complicated pregnancies.
One participant explains their referral system and postnatal care
HC5 Following the implementation of ultrasound service, the midwife can detect abnormalities at the ANC visit. If a severe problem is identified, we immediate action by either calling for an ambulance or requesting assistance e from the surveillance team. The woman is then referred to the hospital, where the midwife sonographer establishes contacts with her colleagues at the referral hospital, ensuring that she receives prompt and appropriate care. During postnatal care, we engage in discussions with women on how to prevent future problems. In cases where women do not come for postnatal care, the field workers of pregnancy surveillance conduct home visits and provide the necessary support and advice.
Create trustworthy work and a sense of fulfilment
According to the participant, the introduction of the ultrasound service at the health centre has brought about a sense of interest and excitement. Previously, conflicts would arise during ANC due to some discrepancies between the health centre’s diagnosis and that of the hospital. However, with the integration of ultrasound, into ANC, midwives are now able to diagnose and manage pregnancy-related complications more effectively. This has resulted in increased acceptance of the maternity service by women, fostering positive relationships between them and midwives. The ability to provide accurate diagnoses and prevent severe complications boosted the confidence and satisfaction of the midwives.
HC6 Previously, our examination of women during ANC relied solely on palpation, which made it difficult to accurately abnormalities, even if we suspected their presence t. Unfortunately, some women who received ANC follow-up ended up experiencing the loss of their child, giving birth to a child with an abnormality, or encountering severe complications. Consequently, they would hold us responsible, feeling that we had assured them of a normal pregnancy without complications. This led to the loss of confidence in our service. However, with the introduction of ultrasound, we are now able to provide women with a clear understanding of their actual condition and promptly refer them for appropriate care. This has resulted in a sense of excitement and satisfaction among those we serve. We, too are immensely pleased with the positive impact of our work.
Reduce devastating conditions
In rural communities in Ethiopia, the birth of a child with congenital abnormalities is often viewed as a sinful occurrence. Women who give birth to such a child are subjected to discrimination, while the community perceives this as an inevitable issue. However, the introduction of ultrasound services has brought hope by allowing the early detection of these abnormalities during ANC. Midwives sonographers play a crucial role in identifying any congenital abnormalities and referring the expectant mothers to hospitals for further medical attention. Following medical treatment, pregnancy surveillance field workers continue to provide health education in the comfort of the women’s homes.
HC7 …by the way, within the rural community, ultrasound technology, referred to as “computera,” is widely acceptable and highly recommended. It is considered the primary diagnostic tool to identify and rule out abnormalities during pregnancy. This shift in attitude has led to a significant decrease in the occurrence of term stillbirths and anencephaly. The decrease can be attributed to the increased frequency of women seeking regular examinations and the prompt action taken by healthcare professionals in response to any detected issues.
Community acceptance
The rural community in Ethiopia holds a favourable view of ultrasound technology and places great trust in its results. They often seek ultrasound scans for minor ailments like abdominal cramps. Consequently, the women in these communities are elated to have access to free ultrasound services at their local health centres. They eagerly attend ANC visits due to the availability of ultrasound services is available. Furthermore, the presence of this service has improved delivery and postnatal care; as they firmly believe that ultrasound can help prevent unfavourable outcomes.
HC8 The introduction of ultrasound services has garnered widespread acceptance and appreciation, not just from service users, but also from the general public in Ethiopia. The community has expressed, their satisfaction, noting that the health center now provides excellent care through the use of ultrasound technology. They consider r the health center as a special health center, as they have previously experienced the challenges of accessing ultrasound services, especially when they were only offered in private clinics. The availability of ultrasound service has not only reduced the cost of ultrasounds from private clinics, where women pay 250ETB per session, but it has also saved them valuable time that would have been spent, searching for ultrasound facilities, as a result, both women and the community as a whole are highly satisfied with development.
One participant explains how the community accepts ultrasound services for delivery and postnatal care.
HC5 Upon learning about the availability of ultrasound services, a considerable number of clients started seeking ultrasounds even for minor ailments, while initially disappointed to discover that the service was exclusively for pregnant women, they have since accepted this restriction. Pregnant women express great satisfaction with the service and frequently return for follow-up appointments. Our recent monthly report also revealed a notable improvement in delivery and postnatal care, further highlighting the positive impact of ultrasound services.
Expansion of the ultrasound services
The participants of this study strongly believe that ultrasound services should be accessible during night-time and weekends. They emphasise that midwives often encounter complications during labour, such as unexplained bleeding, where ultrasound scans are crucial for determining the cause and managing the situation effectively. Currently, the absence of ultrasound services during these hours forces midwives to refer women to hospitals, which can be perilous in severe cases. Consequently, the participants strongly advocate for the provision of ultrasound services during nighttime and weekends, with trained midwives available to administer them. Furthermore, they highlight the need to expand these services to other health centres to cater to all pregnant women in the region.
HC10 In order to enhance healthcare, it is crucial to expand the availability of services in all health centers throughout the week, from Monday to Sunday. This is because pregnant women visit the health frequently visit health centers seeking care, and women in labor may require assistance at any hour of the day or night. Therefore, ensuring that ultrasound services are accessible at all times is essential to improve the quality of care provided.
One participant described her view regarding trained manpower.
HC11 In my opinion, it would be highly beneficial to include trained personnel in our health center, as we have a high level of patient follow-up. I urge the Ministry of Health to consider this matter seriously, as it is crucial for all staff to receive proper training. Additionally, acquiring more machines would greatly contribute to enhancing maternal and fetal outcomes.
Overall, while ultrasound has numerous benefits in improving maternity services, it also presents certain drawbacks. One major challenge is the interruption of electric power in most rural health centres, which hinders the provision of ultrasound services when needed. Additionally, midwives who heavily rely on ultrasound results may be discouraged from performing manual examinations. Consequently, pregnant women are often compelled to return home without receiving comprehensive ANC services due to these limitations.
Discussion
Ultrasound has been recognised as a critical tool in maternity care. However, its accessibility is limited in rural health centres in Ethiopia, which serve as the primary source of healthcare for the majority of rural women. Fortunately, there have been recent efforts to integrate ultrasound services into health centres affiliated with the Kersa, Haramaya and Harar districts in eastern Hararghe. This integration marks a positive step towards improving access to ultrasound services for women in these area.
The objective of this qualitative descriptive study was to explore the perspectives of healthcare providers regarding the improvement of maternity care following the introduction of ultrasound in the selected health centres. Through our analysis, we identified one overarching theme that encompasses the consensus that the introduction of ultrasound has significantly ‘improved maternity care’ and six subthemes within that theme. The categories include ultrasound increases the utilisation of maternity care, ultrasound reduces delays at the healthcare facilities, creates trustworthy work and a sense of fulfilment, reduces devastating conditions, community acceptance and expansion of the ultrasound services.
According to the participants, ultrasound has had a significant impact on maternity care, both in terms of the number of attendees and the quality of care provided The utilisation of ANC services has seen a remarkable improvement since the introduction of ultrasound., Specially, the frequency of antenatal follow-up, ranging from two to four times has significantly increased, whereas it was almost non-existent before. The quality of ANC has also improved, as evidenced by a higher level of client satisfaction and relatively accurate diagnosis. Furthermore, participants noted that ultrasound has influenced delivery and postnatal care as well. Women who undergo ultrasound examination during their ANC visit are more likely to give birth at the same health centre, as they believe the ultrasound contributes to better birth outcomes. Consequently, there has been an increased demand for postnatal and postabortion care at health centres. This finding is consistent with another study conducted in Ethiopia, which demonstrated that access to ultrasound machines contributed to an increase in the uptake of maternal and newborn services in healthcare facilities.14 Similarly, a study conducted in Tanzania indicated that the use of ultrasound at lower-level health facilities led to a higher, percentage of women attending ANC clinics four times or more.18
This study showed that previously, most women from rural areas did not initiate ANC and only sought health centres during labour if complications arose. However, with the introduction of ultrasound, these women now visit ANC either before or immediately after complications occur. This Shift in behaviour has enabled, midwives to easily trace the complication during the ANC visit using ultrasound and facilitate timely referral. Furthermore, midwives are able to establish connections with hospital personnel, leading to early management of complications. This finding aligns with the study conducted in Ethiopia, which indicated that access to ultrasound services improved referrals from health centres and primary hospitals. The ability of midwives to identify complications, make accurate diagnoses and make timely and appropriate referral decisions played a crucial role in this improvement.14 In a qualitative study conducted in Rwanda also indicated the significance of ultrasound in managing pregnancy and labour complications. Physicians emphasised that ultrasound provided them with has immediate and clear diagnosis, instilling greater confidence in making complex decisions.19
Based on the description of the study participants, it is evident that providing ultrasound service utilisation during at nighttime and on weekends would greatly benefit women facing complications. This is because, during these, women encounter various challenges, such as a lack of transportation, poor road conditions and limited access to nearby hospitals, resulting in unfavourable outcomes. By offering ultrasound during these hours, midwives effectively identify and manage complications. This finding is consistent with a qualitative study conducted in Rwanda, which discovered that ultrasound help detect pregnancy complications like suspected ectopic pregnancy, placenta previa, vaginal bleeding and spontaneous abortion, thereby aiding in making informed management decisions.19 To ensure round-the-clock availability of services, it is crucial to train more midwives in ultrasound services. Additionally, the study participants expressed the need for expanding services at all health centres to enhance coverage. This expansion could be a significant contribution to reducing negative maternal and fetal outcomes in eastern Hararghe. This finding is consistent with another study carried out in Ethiopia, which found that a lack of trained midwives at health centres was one of the primary reasons for the absence of continuous ultrasound services.14
The midwives expressed a strong interest and motivation in having ultrasound service in their unit, recognising its crucial role in diagnosing complications and saving women’s lives. They emphasised the significant impact of early detection of complications during ANC n averting fetomaternal morbidity. One common problem they identified with pride was the ability to detect congenital malformation (such as anencephaly). They highlighted how this knowledge protects women from psychological trauma inflicted by societal stigmatisation, as some consider these as a punishment from a higher power ‘Allah’ due to a sin. This finding is supported by previous research, which shows that midwives were motivated and interested in providing ultrasound examinations for pregnant women because it could enable them to diagnose complications and take appropriate action.14 Furthermore, a Canadian study also revealed that patients highly valued the diagnostic information provided by ultrasound imaging and saw it as a tool to help them understand their health and disease better.20
The community has shown a strong acceptance of free ultrasound services provided at nearby health centres. Health centre managers have described how this service not only service promotes health centres themselves but also enhances pregnant women’s health-seeking behaviours. As a result, there has been a notable increase in the number of women receiving ANC, delivery and postnatal care. Additionally, the presence of ultrasound services improved communication between healthcare providers and the women. The same finding was shown in a recent study in Ethiopia, the availability of ultrasound services in primary care increased women’s satisfaction and trust in healthcare providers.14
Strength and limitation
The study primarily focuses on practical aspects occurring within health centres, which are staffed by health professionals. These professionals possess firsthand knowledge and experience regarding the subject matter, enabling them to provide accurate and informed responses regarding day-to-day practices. Therefore, the study is less prone to reporting, selection and information biases. The qualitative descriptive study involved the participation of midwives working in maternity units and health centre managers, ensuring that detailed information about maternity care improvement was collected. However, it is important to note that the study did not include input from women receiving care, which could have resulted in a more comprehensive understanding of the topic. Due to its qualitative nature, the study may have limitations regarding external validity, but the findings can still be transferable to similar contexts. Additionally, it should be acknowledged that there may be a loss of meaning in the participants’ actual words during the process of transcription and translation from the original language to English
Conclusion and recommendation
The use of ultrasound service at health centres has improved maternity care. The utilisation of ultrasound in healthcare enables providers to closely monitor the growth and development of the fetus, identify potential complications or abnormalities and administer timely interventions. This integration of ultrasound technology translates into enhanced prenatal care, early detection of issues and prompt management, ultimately leading to improved outcomes for both the mother and the baby. By incorporating ultrasound into ANC practices, healthcare providers can offer comprehensive and effective perinatal care, contributing to healthier pregnancies and safer deliveries for pregnant women. The valuable lesson for healthcare professionals and stakeholders is providing a practical insight on how to implement similar activities in other health centres. By adopting this approach, there is a hopeful expectation of improving maternal healthcare and preventing avoidable complications during pregnancy.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The CHAMPS pregnancy surveillance activity which has ethical clearance for its main activity and the pregnancy surveillance from Haramaya University Colleges of Health and Medical Sciences Institutional Health Research Ethical Review Committee and National Health Research Ethical Clearances office with reference number V/P/R/A/11/288/22. Respondents were fully informed about the purpose of the study and confidentiality and the purpose of this qualitative descriptive study. The information obtained during the study was kept confidential and used only for research purposes. Names and identifiers of the study participants were not collected. Before the interview, the participants provided written informed consent after receiving detailed information about the benefits, risks and possible termination of their study participation.
Acknowledgments
We would like to acknowledge all study participants for their unreserved support in providing information and for the data collector for their endurance during the data collection process.
Footnotes
Contributors All (MT, HM, NA and MJ) planned the study; MT and HM supervised in-depth interviews, analysed the data and prepared the manuscript. NA and MJ particpated in the anlaysis of the data. MT prepared the manuscript, and the rest of the team (HM, NA and MJ) reviewed and confirmed it. MT is a guarantor the work.
Funding The authors have not declared a specific grant for this research. All the authors are involved in the CHAMPS pregnancy surveillance activities.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.