TY - JOUR
T1 - Standardization and quality control of Doppler and fetal biometric ultrasound measurements in low-income setting
AU - Ali, S.
AU - Byamugisha, J.
AU - Kawooya, M. G.
AU - Kakibogo, I. M.
AU - Ainembabazi, I.
AU - Biira, E. A.
AU - Kagimu, A. N.
AU - Migisa, A.
AU - Munyakazi, M.
AU - Kuniha, S.
AU - Scheele, C.
AU - Papageorghiou, A. T.
AU - Klipstein-Grobusch, K.
AU - Rijken, M. J.
N1 - Funding Information: We thank the study participants, Kagadi District Health Team, The Woman's Place, ECUREI and Makerere University College of Health Sciences for supporting the implementation of the EPID project. We are indebted to the University of Oxford, Oxford, UK, for contributing the ultrasound equipment for data collection. Further, our gratitude goes to Fosca Tumushabe who assisted with the English language review. We thank the INTERGROWTH-21st consortium for assistance and for providing freely available training materials and protocols (https://intergrowth21.tghn.org/) and Lior Drukker for his help in calculating umbilical artery Doppler centiles. This project was funded by Grand Challenges Canada through a generous grant (number: R-ST-POC-1808-17038) to Makerere University College of Health Sciences. S.A. is supported by the UMC Utrecht Global Health Support Program (reference: FM/ADB/D-18-015006), University Medical Center Utrecht, Utrecht, The Netherlands. A.T.P. is funded by the Oxford Partnership Comprehensive Biomedical Research Centre with funding from the NIHR Biomedical Research Centre funding scheme. Publisher Copyright: © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
PY - 2023/4
Y1 - 2023/4
N2 - Objective: The aim of this study was to determine the quality of fetal biometry and pulsed-wave Doppler ultrasound measurements in a prospective cohort study in Uganda. Methods: This was an ancillary study of the Ending Preventable Stillbirths by Improving Diagnosis of Babies at Risk (EPID) project, in which women enroled in early pregnancy underwent Doppler and fetal biometric assessment at 32–40 weeks of gestation. Sonographers undertook 6 weeks of training followed by onsite refresher training and audit exercises. A total of 125 images for each of the umbilical artery (UA), fetal middle cerebral artery (MCA), left and right uterine arteries (UtA), head circumference (HC), abdominal circumference (AC) and femur length (FL) were selected randomly from the EPID study database and evaluated independently by two experts in a blinded fashion using objective scoring criteria. Inter-rater agreement was assessed using modified Fleiss' kappa for nominal variables and systematic errors were explored using quantile–quantile (Q–Q) plots. Results: For Doppler measurements, 96.8% of the UA images, 84.8% of the MCA images and 93.6% of the right UtA images were classified as of acceptable quality by both reviewers. For fetal biometry, 96.0% of the HC images, 96.0% of the AC images and 88.0% of the FL images were considered acceptable by both reviewers. The kappa values for inter-rater reliability of quality assessment were 0.94 (95% CI, 0.87–0.99) for the UA, 0.71 (95% CI, 0.58–0.82) for the MCA, 0.87 (95% CI, 0.78–0.95) for the right UtA, 0.94 (95% CI, 0.87–0.98) for the HC, 0.93 (95% CI, 0.87–0.98) for the AC and 0.78 (95% CI, 0.66–0.88) for the FL measurements. The Q–Q plots indicated no influence of systematic bias in the measurements. Conclusions: Training local healthcare providers to perform Doppler ultrasound, and implementing quality control systems and audits using objective scoring tools in clinical and research settings, is feasible in low- and middle-income countries. Although we did not assess the impact of in-service retraining offered to practitioners deviating from prescribed standards, such interventions should enhance the quality of ultrasound measurements and should be investigated in future studies.
AB - Objective: The aim of this study was to determine the quality of fetal biometry and pulsed-wave Doppler ultrasound measurements in a prospective cohort study in Uganda. Methods: This was an ancillary study of the Ending Preventable Stillbirths by Improving Diagnosis of Babies at Risk (EPID) project, in which women enroled in early pregnancy underwent Doppler and fetal biometric assessment at 32–40 weeks of gestation. Sonographers undertook 6 weeks of training followed by onsite refresher training and audit exercises. A total of 125 images for each of the umbilical artery (UA), fetal middle cerebral artery (MCA), left and right uterine arteries (UtA), head circumference (HC), abdominal circumference (AC) and femur length (FL) were selected randomly from the EPID study database and evaluated independently by two experts in a blinded fashion using objective scoring criteria. Inter-rater agreement was assessed using modified Fleiss' kappa for nominal variables and systematic errors were explored using quantile–quantile (Q–Q) plots. Results: For Doppler measurements, 96.8% of the UA images, 84.8% of the MCA images and 93.6% of the right UtA images were classified as of acceptable quality by both reviewers. For fetal biometry, 96.0% of the HC images, 96.0% of the AC images and 88.0% of the FL images were considered acceptable by both reviewers. The kappa values for inter-rater reliability of quality assessment were 0.94 (95% CI, 0.87–0.99) for the UA, 0.71 (95% CI, 0.58–0.82) for the MCA, 0.87 (95% CI, 0.78–0.95) for the right UtA, 0.94 (95% CI, 0.87–0.98) for the HC, 0.93 (95% CI, 0.87–0.98) for the AC and 0.78 (95% CI, 0.66–0.88) for the FL measurements. The Q–Q plots indicated no influence of systematic bias in the measurements. Conclusions: Training local healthcare providers to perform Doppler ultrasound, and implementing quality control systems and audits using objective scoring tools in clinical and research settings, is feasible in low- and middle-income countries. Although we did not assess the impact of in-service retraining offered to practitioners deviating from prescribed standards, such interventions should enhance the quality of ultrasound measurements and should be investigated in future studies.
KW - Doppler ultrasound
KW - antenatal
KW - developing country
KW - quality assurance
KW - reliability
KW - training
UR - http://www.scopus.com/inward/record.url?scp=85143273132&partnerID=8YFLogxK
U2 - https://doi.org/10.1002/uog.26051
DO - https://doi.org/10.1002/uog.26051
M3 - Article
C2 - 37011080
SN - 0960-7692
VL - 61
SP - 481
EP - 487
JO - Ultrasound in Obstetrics & Gynecology
JF - Ultrasound in Obstetrics & Gynecology
IS - 4
ER -