This mother, unlike many others in Uganda, had a healthy pregnancy and successful delivery.
This mother, unlike many others in Uganda, had a healthy pregnancy and successful delivery.
Mobile health has tremendous potential to ease suffering and provide healthcare to individuals who have restricted access to medical staff, facilities, and technology. Many women around the world, particularly those in rural communities with few resources, have limited access to basic maternity health information, and such areas rarely have either ultrasound equipment or trained personnel to operate the equipment.
As a result, preventable but untreated pregnancy and childbirth complications lead to large numbers of maternal and infant deaths in developing nations.1 One of the World Health Organization's Millennium Development Goals is to improve global maternal health by reducing maternal mortality and increasing skilled care.2 More than half of the 358,000 maternal deaths that occur annually can be attributed to hemorrhage or obstructed labor.
Increased access to prenatal obstetric ultrasound imaging could significantly reduce maternal and neonatal mortality rates in such populations. Antenatal care and access to ultrasound provide an opportunity to identify high-risk pregnancies and detect debilitating complications. A higher level of care at delivery can then be arranged in advance.
Current barriers to deployment of ultrasound in remote areas include expensive equipment, high electrical power requirements, and the need for highly trained ultrasound operators. Traditional ultrasound programs involve six months to two years of training and are limited to on-site diagnoses. Such programs are expensive, time-consuming, and have limited sustainability.
Current barriers to deployment of ultrasound in remote areas include expensive equipment, high electrical power requirements, and the need for highly trained ultrasound operators.
Together with G. Eli Morey (also at the University of Vermont), Matthew Rielly and Martin Anderson (Philips Healthcare), Alphonsus Matovu (Kamuli Mission Hospital, Kamuli, Uganda), Brian Garra (U.S. Food and Drug Administration), Michael Kawooya (Mengo Hospital, Kampala, Uganda), and Frank Miele (Pegasus Lectures, Inc.), a mobile-based obstetric care model was established to address these challenges. The program has been tested, validated, and shown to reduce mortality and improve outcomes at delivery.3
Static images from a volume scan “sweep” of a second trimester fetal presentation of the head (A) and placenta (B) at Nawanyago Health Center.
Static images from a volume scan “sweep” of a second trimester fetal presentation of the head (A) and placenta (B) at Nawanyago Health Center.
Training a healthcare worker to generate ultrasound volume images with the portable ultrasound system.
Training a healthcare worker to generate ultrasound volume images with the portable ultrasound system.
To monitor the status of her pregnancy, a woman in rural areas of the Kamuli district previously had to travel 50 kilometers to have an ultrasound.
Uganda's eastern Kamuli district was the site chosen to implement the care model, as maternal and infant mortality rates in Uganda are amongst the highest in the world. A woman in Uganda has a 1 in 30 lifetime chance of dying from complications of childbirth compared to 1 in 5,600 in developed regions of the world.1 Other regions in sub-Saharan Africa have maternal mortality rates that are comparable to those in Uganda.
Most deliveries in the country occur at home with traditional birth attendants. Only about one-third of deliveries occur in rural health facilities. These facilities have skilled birth attendants but no surgical services. Transport to a Ugandan district hospital for a higher level of care is time consuming, and both mother and child therefore have a high risk of a poor outcome if there is an unanticipated obstetric emergency.
To monitor the status of her pregnancy, a woman in rural areas of the Kamuli district previously had to travel 50 kilometers to have an ultrasound. However, with this novel mobile health model, expectant mothers in remote locations can have obstetric complications detected early and can receive treatment or transfer to better healthcare centers in time.
The team is successfully using mHealth to make obstetric ultrasound accessible to the most rural health clinics in Uganda, and provide high-quality, advanced diagnoses. The key components of the model are:
A portable ultrasound machine
Volume scanning protocols for local clinical data acquisition
Custom clinical data compression and transmission capabilities
An internet-based infrastructure for remote reading and reporting ultrasound diagnoses
Novel ultrasound protocols that use volume scanning—in which series of images are generated in place of still ultrasound images—have high diagnostic quality, and require little operator-training time. To date, the use of volume ultrasound scanning to prevent maternal/fetal morbidity and mortality has not been described by any other research groups.
Volume scanning creates one highly accurate ultrasound image (from high frequency sound waves and their echoes) for every millimeter that the transducer covers when it is swept across the body area of interest. Single images from a series together render a volume imaging “sweep” or cine loop, that looks like a short video clip. Each 3-D volume abdominal sweep therefore yields a series of images similar to computed tomography (CT) or magnetic resonance imaging (MRI) scans.
The key advantages to this obstetric care model are that far more diagnostic quality images and more complete organ coverage are obtained than in traditional scanning that relied on a few representative images, and that the portable scanner can be used in the field without specialist medical knowledge of the anatomy to be scanned.4,5
This technology-based solution makes it possible for minimally trained primary healthcare workers, like nurse midwives at a rural clinic, to generate ultrasound volume images that capture key maternal-fetal anatomy. Requiring only a few hours of hands-on training, they are taught to do this by using external anatomic landmarks of the mother and sweeping the ultrasound transducer over the pregnant abdomen.
The system includes:
A laptop ultrasound system
A low-power netbook computer-based local storage and transmission server
A connection to the ultrasound system via wireless Ethernet
A connection to the remote imaging collaboration server (Datarealm Services, Inc., Phoenix, AZ) via cellular modem or other Internet connection
Body volume imaging exam data—images that resemble a video clip—from rural clinics are compressed and transmitted to a remote picture archiving and communication system (PACS) via the Internet for interpretation using a local mobile phone network. An integrated compression and transmission system automatically detects the Internet bandwidth and appropriately adjusts the packet size of the file to upload it to a server where it can be accessed by imaging experts anywhere in the world.
Medical experts review the data remotely by scrolling through the images for key pathology or high-risk indicators, and transmit their findings via mobile phone text message back to the rural clinics and the regional referral hospital. A standardized structured reporting system creates an infrastructure that promotes reliable diagnostic reporting and also creates a means for outcomes tracking, peer review and quality assurance monitoring (Figure 1).
Mobile health obstetric care model image and report flow from scanner to electronic report.
Mobile health obstetric care model image and report flow from scanner to electronic report.
Medical experts review the data remotely by scrolling through the images for key pathology or high-risk indicators, and transmit their findings via mobile phone text message back to the rural clinics and the regional referral hospital.
This innovation is a lifesaver, as the images can be obtained by trained healthcare workers and sent via cell phone to medical experts located anywhere in the world who can interpret the scans and return a diagnosis by email, instant message or cell phone within a short period of time. A low-cost, clinically accurate diagnosis can therefore be made wherever a cell phone signal is available, the patient does not need to travel to a clinic, and advance notice of a critical condition or emergency can be given.
Ugandan healthcare workers estimate that the ultrasound project will increase diagnostic rates for important gestational conditions and save the lives of over 30 mothers and their babies annually in the Kamuli district alone. In one year of implementing the program, our team observed a 70% increase in antenatal visits and deliveries at Nawanyago clinic compared to the previous year, as well as the transfer of several patients for hospital deliveries.
The cost of setting up the program in a health center is about US $10,000, and the program is now being implemented in other districts. Subsequent phases of supervised training allow for basic interpretations of the obstetric ultrasounds to be performed by the same nurse midwives at the rural health center, maintaining the practice of transmitting images to the Internet for peer review and diagnostic quality assurance.
The system also provides for remote expert interpretations as a “back-up” in the setting of problem cases or volume overload. Finally, a subset of these nurse midwives will go for further training to become full sonographers. They then become “train-the-trainers” in the mobile health obstetric care model, allowing for a fully sustainable solution. Another effect of the program is a heightened awareness of the importance of medical screening: Women receiving ultrasounds stay to be screened and treated for other health conditions such as malaria, syphilis, and HIV.
Together with a robust community education program, two years following implementation, this mobile, integrated health care delivery system is demonstrating a positive impact on maternal-fetal health in Uganda by saving lives. This innovative, integrated solution combines many elements that together create a new paradigm for improved antenatal care in resource-constrained areas and can be applied in many other low-resourced areas of the world.