Approaches, barriers, and facilitators to and strategies for normalizing the provision of ultrasound scanning by midwives in the antenatal clinic

Abstract

The World Health Organization (WHO) recommends that a pregnant woman get an ultrasound scan (USS) as part of routine antenatal care. The Scale-up and normalization of ultrasound scanning still lag in low- and middle-income countries (LMIC), including Malawi. This study assessed barriers, facilitators, and strategies for scaling up and enhancing the normalization of ultrasound scanning during pregnancy in Malawi.

Method

We conducted one qualitative participatory workshop in each of Malawi’s administrative regional cities, including one workshop in the southern region on 17–18 May 2022, one in the Central region on 20–21 May 2022, and one in the Northen region on 23–24 May 2022. Forty USS trained and untrained midwives, one maternal and neonatal Zonal manager from the Ministry of Health (MoH), two District Nursing Officers (DNO), three district safe motherhood coordinators, and two Tutors from Nursing and Midwifery training institutions participated in the workshops to explore barriers, facilitators, and strategies and develop a training manual for scaling up ultrasound scanning in routine antenatal care (ANC) in Malawi. In addition, a validation workshop was conducted centrally in the central region, on September 22–23, 2022, with four representatives from the Ministry of Health, one from regulatory bodies, three from training institutions, one sonographer, and 10 district and Principal Nursing Officers (PNO) and midwives to validate the manual, which was developed with input from workshop participants. Data was audio recorded throughout the discussion, coded, and thematically analysed using NVivo 12 software.

Results

The barriers to normalization of USS in routine care include limited capacity and resources, such as a lack of USS-trained staff, infrastructure, including electricity interruptions, and misconceptions. The facilitators to normalization include political will to offer USS, availability of resources including trained midwives, restructuring of service provision, task sharing, revisions of staff allocations, and service integration. The strategies include preservice and on-the-job training, support and supervision, increased availability of resources, improved facility infrastructure, and community sensitization.

Conclusion

Scaling up of ultrasound is possible in Malawi. Staff training, community sensitization, and adequate human and material resources, including a standardised training manual, should be considered when planning USS scale-up and normalization into routine ANC.

Introduction

The implementation of innovative medical technologies such as ultrasound scanning (USS) at antenatal care is recommended to improve gestational age accuracy and thereby improve maternal care and fetal outcomes. Obstetric USS is widely utilized in higher income countries for screening and evaluation of pregnancy complications, fetal viability, placental status, pregnancy status and dating a pregnancy, but its use has lagged in lower-income countries [1, 2]. The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation for pregnant women to estimate gestational age, improve the detection of fetal anomalies and multiple pregnancies, reduce the induction of labour for post-term pregnancy, and improve a woman’s pregnancy experience [3]. The importance of this service cannot be overemphasized, especially in low-income countries where adverse pregnancy outcomes such as preterm birth and intrauterine growth restriction are high [4]. Malawi, as one of the lowest-income countries, has the highest preterm birth rate in the world, at 18.1% of total births [5–7].

Although Malawi adopted the WHO recommendation on ANC in 2019 and developed the ANC Matrix and antenatal care guidelines to accelerate implementation [8], there were no mechanisms in place to roll out the provision of ultrasound scanning among pregnant women before 24 weeks gestation in public health facilities. Realizing this gap, the DIPLOMATIC research group [9] comprising researchers from Malawi, England, and Zambia, developed a novel training course that was used in training midwives on USS in Malawi on three fundamental components of early antenatal ultrasound scanning, encompassing identification of the number of fetuses, confirmation of fetal viability, and determination of gestational age (TUDA study) [1]. This training was rolled out in January 2021 in six sites in Malawi, including three primary health centres in Blantyre, one primary health centre in Lilongwe, and one rural and a district hospital in Karonga. In total, 29 midwives were trained and 28 gained competencies assessed through Observed Structured Clinical Examinations (OSCEs) and ability to estimate clients’ gestational age within ± 7 days of the trainers’ measurements. TUDA was an independent study and its comprehensive description and results are published elsewhere [10, 11]. Given that there is convincing evidence of the benefits of USS and ensuring that it reaches all pregnant women and having realised that midwives in Malawi could be trained to provide the service, scaling up was considered as the next step. Scaling up comprises deliberate efforts to accelerate the implementation and increase the impact of successfully tested interventions to benefit more people while advocating for policy and programmatic commitments to achieve sustainability [12]. Scaling up of interventions requires an assessment of the readiness of the context to roll out the services and identifying potential challenges that can be incurred during the process [13]. A successful scale-up and normalization of public health interventions guarantees that the service will reach more people and remain equitable for all end-users while also accelerating accessibility of the services for marginalized pregnant women [14]. A prerequisite to scaling up USS services entailed an assessment of the factors that would influence the normalization of the USS in routine antenatal care. Specifically, in this study, we explored the barriers, enablers, and strategies to the normalization of ultrasound scanning by midwives in routine antenatal care services.

Conceptual framework

The study team selected organisational readiness framework to guide the study [15]. The conceptual framework was chosen based on its strong relevance to the research objectives and the context in which the study was conducted. This framework supports a systematic analysis of key health system factors such as organisational culture, resources, leadership, and decision-making that shape the normalisation of services and users’ experiences. Specifically, the study was informed by two constructs of change valence and change efficacy. Change Valence take into consideration how different groups of stakeholders perceive the upcoming change, while change efficacy assess psychological readiness and commitment to implement change and a forecast of what might happen in future [14, 16]. The use of an organizational framework was pertinent since it emphasizes the importance of collective commitment and change efficacy in guaranteeing the successful execution of health interventions. Leveraging on USS experienced midwives, stakeholders debated and unveiled both systems and individual barriers and facilitators to scale up and normalising USS in routine ANC. Readiness refers to attributes such as financial resources, technical resources, capabilities, human resources, knowledge, skills, members attitudes, beliefs, and intentions to implement change [17].

Methods

Study design

This exploratory qualitative study involved the use of participatory consensus workshops. We employed participatory approaches [18] to encourage stakeholders to co- identify facilitators and real or potential problems that may occur with the process of scaling up, normalizing, and sustaining USS in routine ANC. Good problem solving requires input from a variety of people with many types of experience and expertise in the field of interest. In addition to increasing a sense of responsibility and ownership of the program, this participatory approach allowed for the inclusion of everyone’s suggestions to determine the best contextualized approach in the normalization process.

Study setting

The study took place in all three regions of the country. Malawi is divided into three administrative regions and subdivided into twenty-eight districts. The health care system in Malawi operates on a three-tiered health system, including primary, secondary, and tertiary levels of care. The primary level includes health centres and rural hospitals, where most of the population at the community level, including maternal, neonatal, and child health services, are initially received. The primary level of care links with district hospitals which are the secondary and central hospitals as tertiary levels hospitals for advanced or complicated care through an established referral system. The primary-level facilities are managed by the District Health Office (DHO) management team based at the district health office. The districts are further grouped into zones. Malawi has five health support zones, including the north zone, the east and west in the central region, as well as the east and west in the southern region. The DIPLOMATIC study sites included three primary-level facilities in Blantyre in the southern region, one primary facility in Lilongwe, the central region, and two facilities, both primary and secondary in Karonga, in the northern region.

These facilities were both rural and urban health care centres providing maternal, neonatal and child health care services and were previously selected to participate in the TUDA Ultrasound training Study [19]. Facilities included Zingwangwa, Mpemba and Ndirande health centres in Blantyre in the southern region, Area 25 health centre in Lilongwe, in the central region and Chilumba rural hospital and Karonga District hospitals in Karonga, in the northern region. These are categorised as high volume primary and secondary maternal and neonatal care health facilities in their respective districts. USS experienced participants from these sites were invited to participate in the participatory workshops.

Participants recruitment

This study involved diverse groups and cadres of stakeholders from the health care system to participate in participatory workshops to explore what they perceive to be barriers, facilitators and strategies for USS scale up and normalisation in routine Antenatal care services. Participants were invited through invitation letters sent through the DHOs to identify and invite midwives who participated in USS training at the DIPLOMATIC study sites. We also invited midwives from rural primary facilities who actively managed maternity services but were not trained in USS to attend the workshops. These midwives were selected based on their role as key providers of antenatal care to women at high-volume facilities and their engagement in service improvement. In addition, District Nursing Officers from Lilongwe, Blantyre and Karonga in their capacity as health managers responsible for Nursing and Midwifery services in the districts were invited [20]. The DHO and their DNO oversee the nursing and maternity care activities within health facilities in each district.

Sample selection and size

We drew a purposive sample to include specific characteristics of people we deemed to have rich information on the issue for us to achieve a broader scope of nuances, experiences, and suggestions on the discussion (Table 1) [21]. Thus, our sample included TUDA-USS trained and implementing midwives, USS untrained midwives, from rural, and urban- facilities, DNOs, nurse midwife tutors from training institutions, and Maternal and Neonatal zonal managers. The selection of individual midwives from the sites both USS trained and untrained, rural or urban was facilitated by the district health office.

Table 1.

Cumulative number and cadre of participants in the first three workshops

Type of Personnel	Number	Types of Participants	Rationale for participation
Midwives	12	USS experienced.	They have had lived experiences with conducting USS in routine ANC and would provide real experiences to guide the normalization process.
	28	USS untrained	They are well experienced in midwifery and knowledgeable of gaps in ANC and would provide the information on how they can integrate USS services in their sites
	15	Rural based	Provided rural contexts gaps, strengths and areas which needs strengthening to roll out and scale up USS to the rural facilities.
	25	Urban-based	Urban hospitals midwives mostly have access to resources, networking and collaborating, and expertise hence a source of diverse perspectives on normalisation and sustainability of USS.
Managers	1	Maternal and neonatal health Zonal managers	These are responsible for quality management supervision at zonal level. They would provide guidance on services to maintain quality
District Nursing Officers	2	District Nursing and Midwifery Officers from each participating District	These are the custodians of Midwifery care in each district and would provide oversight of nursing services
District Safe motherhood Coordinators	3	District Safe Motherhood Coordinators	Management of Antenatal care services is one of their key responsibilities and they would provide information pertaining to their District as far as Antenatal care is concerned with regards to incorporating USS services
Tutors	2	Tutors from Midwifery Teaching Institutions	Their expertise in maternal health and prenatal care teaching would provide valuable insights into the practical application of ultrasound scanning in ANC. Tutors directly guide, supervise, and support students in academic and practical settings. Their involvement ensures the intervention can be delivered consistently and correctly during routine teaching and mentorship. Tutors are key during implementation of USS in pre - service training.

Data collection

Description of data collection tools

The participatory approaches used tools like gallery walks, nominal group techniques, and quality improvement techniques such as fish bone and affinity diagrams. Gallery walking is a technique used to conduct group work. It consists of groups walking through set stations and having group members contribute their ideas at each station. It encourages active participation and instills courage and enthusiasm in participants in a group [22]. A nominal group technique was used to facilitate agreement among members of the group, rating important ideas based on priorities setting process [23]. While gallery walks and nominal group techniques were for generation and prioritizing ideas, participants also used a fishbone to brainstorm the underlying causes of a real or potential problem and help determine corrective and preventive interventions [24]. A fishbone visual diagram resembles anatomical features of branching fish bones and provided participants with an opportunity to perform a cause-and-effect analysis of a problem and propose a corrective and sustainable solution [25].

An affinity diagram is a tool for organizing, categorizing and consolidating large amounts of unstructured data to make sense of it [26]. Affinity diagram assembles independent but related ideas into meaningful groups, making it easier to interpret patterns that emerged generated from group discussions [27].

Training of facilitators

Prior to the conduct of participatory workshops, researchers and two USS trained female midwives from two of the DIPLOMATIC study sites in Blantyre were trained on November 29, 2021. The training workshop conducted by the principal investigator focused on best practices regarding facilitation and data management during participatory workshops. During the training, the group simulated the techniques that were to be used in the study, which included gallery walks, affinity diagrams, fishbones, and nominal group techniques.

In addition, prior to implementing participatory workshops, the study team received training in qualitative data collection and management held on June 29, 2022, in readiness for the data that would be generated from participatory workshops. At the start of the participatory workshop, the participants received a protocol overview to bring the group into context since some members were new to DIPLOMATIC studies. The presentation included an orientation to the tools that were used to reach the consensus during the workshops.

Data were gathered using multiple approaches including note taking during discussions, making summaries of agreed points into affinity diagram and audio recorded all discussion throughout the workshop. At the end of each workshop, data on affinity diagram from each group were compiled into one diagram for the whole group.

Workshop procedures

We conducted one participatory workshop in each of Malawi’s administrative regional cities to enhance participants convenience. Each workshop took two days to complete. One workshop happened in Blantyre in the southern region on May 17 and 18, 2022, one in Lilongwe, the central region, on May 20 and 21, 2022; one in Mzuzu, the northern region, on May 23 and 24, 2022, and one validation workshop was held centrally in Lilongwe on September 22–23, 2022. We used the same selection criteria for participants in all the regions.

During the Workshop, participants were then divided into five groups according to their disciplines, including midwives with USS experience group, midwives with no USS experience group, DNOs with Safe Motherhood coordinators, and zonal supervisors with training institution group. Dividing the groups according to cadres helped participants critically view and discuss ideas in the context of the service they provide without being shadowed by other perspectives.

First day of the workshop

On the first day we employed gallery walks, Fishbone diagrams and summarized the findings from the workshop in affinity diagrams. We set up gallery walk stations with pre-planned themes (Fig. 1) and followed the rules of gallery walks of ensuring that participants took walks through the stations and reviewed what an earlier group had put up on the station, questioned areas that were unclear and added aspects that they felt were missing on a specific station [22] The thematic areas included: (1) What to include in the training manual: (2) Facilitators to USS normalization, (3) Barriers to USS normalization; (4) Resources required; and (5) Strategies to scale up and normalize USS and (6) Experiences with USS. Each station had a facilitator who was guiding the discussion by introducing probes in a systematic way using a guide to get al.l the information required from that station. All discussions were audio recorded to ensure that every discussion is captured.

Fig. 1.

Using gallery walks for critique and revision in project based learning (PBL)

Each group walked through all stations, brainstormed, debated, and shared ideas and synthesized, critiqued, and revised other groups ideas on the theme in relation to USS scale-up and normalization into routine ANC (diagram 1). At each station, participants reviewed colleagues’ ideas and commented on areas of convergence and where they had divergent views, they indicated their views and had sought clarity from the group that owned the idea. To denote agreement, they would tick (I like or agree (√)) or a question mark against an idea they do not agree with or are not sure (I wonder or disagree (?)). After all the groups visited and contributed to each station, we held a plenary session that was coordinated by a researcher to discuss the outcomes of the gallery stations. The researchers facilitated the feedback session by going through each station’s flip chart. In statements with question marks, the groups that had concerns were given a chance to ask or seek clarification on any statement or idea they did not agree with or wonder about until all areas were resolved.

The station on barriers to normalization of USS in routine ANC had a Fish bone diagram. The Fishbone diagram was used to identify real and potential problems, deeply explore the causes and effects of the identified problems and challenges that may surface when normalizing USS in routine ANC. A Fishbone encouraged participants to think deeply about a problem and find opportunities for improvement [28]. All discussions were audio-recorded. Findings and ideas from the gallery walk and fish bone diagram were summarized into an affinity diagram to provide a quick illustration of the main points emanating from the discussions.

Affinity diagram

The researchers thematically compiled in stacks all qualitative data collected during the gallery walk and the fish bone diagram into an affinity diagram for each group (Fig. 2). At the end of each day of the workshop, all affinity diagrams from the groups were compiled into one document comprising summarised views from the gallery stations. The affinity diagram accelerated organization of all ideas on the thematic areas including, barriers, facilitators, strategies and content of a standard training manual to normalize obstetric USS in routine ANC [26].

Fig. 2.

An example of a summarised affinity diagram of all thematic areas

Second day of workshop

We ran a modified Nominal Group Technique (NGT) exercise to produce the five best priorities from the ideas compiled on the Affinity diagram emanating from the predetermined themes. An NGT is a structured face-to-face meeting that facilitates comparison and consensus prioritization of ideas [23]. Prior to engaging in the NGT process, the compiled affinity diagram was presented to participants for review. Any discrepancies were discussed, resolved, and adopted. The ideas for manual content were all considered relevant and were adopted as it was in the affinity diagram to provide rich information for the training manual to guide future standardised USS training.

Nominal group technique process

The participants proceeded with a modified Nominal Group Technique process to rank ideas of highest priority on the list following a systematic approach. Through intensive selection, debates, discussions, and appraising each idea’s merits, a selection of the first to the fifth positions of barriers, facilitators, resources, and strategies for scaling up and normalizing USS in routine ANC were selected and endorsed. The process of participatory workshops is illustrated in Fig. 3.

Fig. 3.

Summarised process of conducting participatory workshops

Training manual development and validation

In addition to exploring strategies, resources, barriers, and facilitators to USS normalization, we also aimed to improve the content of the training manual to be standardized for scaling up and normalizing USS in ANC. The process of manual development took three steps starting from participatory workshop, writing session and Validation workshop (Fig. 4). During the participatory workshops, data were collected on information that should be added or removed from the existing training manual. Following the participatory meeting the research team had a writing workshop from August 22 to 26, 2022, for the researchers to thoroughly review the feedback and the proposed ideas from participants with an aim of incorporating the changes into the manual. During the writing workshop, each researcher was assigned sections of the TUDA training manual requiring revision to take the lead in facilitating the revision. Each researcher independently reviewed feedback and revised the sections. The revised sections were merged and reviewed by the researchers to make sure all stakeholder unified suggestions were incorporated, and any discrepancies and omissions were discussed and corrected. The final document (Fig. 5) was produced and ready for stakeholder validation.

Fig. 4.

Process of developing an USS training manual

Fig. 5.

Facilitators, barriers, resources, and strategies

Validation workshop

A two-day validation workshop was conducted centrally in Lilongwe, the central region, on September 22–23, 2022, to review and validate the training manual. We invited a new group including USS experienced midwives and senior-level stakeholders who are also policymakers to the validation workshop. This new group had a total of 19 participants including a representative from regulatory bodies that regulate the training syllabus and scope of work for clinicians, from Medical Council of Malawi [29], four from the Reproductive health, quality improvement and nursing directorates at the Ministry of Health, ten Midwives and Midwives managers, three representatives from the public and private training institutions. In addition, a sonographer from Imaging Malawi, a team that facilitates ultrasound training programs and workshops in the country in collaboration with the Ministry of Health, attended the validation workshop (Table 2). This was to ensure the training manual content is compliant with the standards for basic ultrasound training.

Table 2.

Participants to validation workshop

Types of Participants	Number	Rationale for participation
Nurse Midwives	3	They have lived experiences with maternity care services, and would provide real experiences and refine the service and rationale for the chosen content in the manual
Principal Nursing and district nursing officers (PNO, DNO)	7	These are policymakers at a District level and with decentralization of services, they are likely to make decisions over midwifery services in their settings.
Sonographer	1	They have experience in sonography and would provide constructive feedback on standards of training and USS services
Ministry of Health Zone supervisors Quality improvement directorate Reproductive health directorate Nursing directorate	4	Key policy makers and have influence on what will be taken up as policy and routine in services. They guide and monitor the integration of Sexual and Reproductive Health Services (SRH) at all levels.
Training Institutions	3	These have a critical role in incorporating USS in preservice training.
Regulators Medical council of Malawi.	1	They oversee the scope of practice for clinicians. They are key in providing guidance on quality of training, and how and at what point an innovation be incorporated in the training syllabus.

Data management and analysis

Data from workshop discussions were compiled into an affinity diagram, while Audios were transcribed directly into English. The data were analysed using thematic analysis as described by; Willig and Clara (2017) [30]. The researchers read the transcripts repeatedly to familiarise themselves with the data. Data coding commenced with predetermined themes (Table 3) which served as discussion points during the gallery walks including barriers, facilitators, strategies, and training manual content to normalise USS in routine ANC. The coding process was open to refining the themes or generating sub themes from the preexisting themes while working through the transcripts. We developed a codebook to describe each code and guide the coding process. We applied organizational readiness constructs as described by Weiner (2020) [17] to categorize the predetermined and emerging themes in the data. All themes were aligned with the readiness construct, including: (1) psychological readiness; (2) contextual factors; (3) resource endowment; (4) organizational structures; and (5) change valence and efficacy. We defined the themes by searching the data for common elements.

Table 3.

Predetermined themes

	Predetermined themes	Allied readiness construct
1	What to include in the Manual	Resource endowment: Valuable possession or something of quality such as a quality manual
2	USS experiences	Contextual Factors. Experience with USS can foster organizational readiness.
3	Barriers and facilitators of USS implementation	Psychological Readiness: This was to determine whether participant is on the continuum between “not prepared to change” and “already changing,” and promote identification and discussion of perceived barriers to change
4	Resources needed	Change efficacy. Assessing if members have the resources or what resources are required to implement USS
5	Strategies to the implementation and normalization of USS in routine services were collected.	Change valence. The passion to identify strategies for implementation

Ethical considerations

The College of Medicine (COMREC) and the University of Liverpool Research Ethics Committees reviewed and approved the study prior to the conduct of any research activity (COMREC, P.11/21/3461/ UK Ethics 10923). All research and implementation staff were trained in human protection and good clinical practices prior to the start of data collection. All participants in the workshops provided written informed consent prior to participation in the discussions.

Patient and public involvements

We did not involve the patients and the public in the design and implementation of participatory workshops.

Results

A total of forty-eight participants participated in the participatory workshops. The Blantyre workshop had fifteen participants; the Lilongwe workshop had sixteen participants and Mzuzu workshop had seventeen participants. Nineteen participants attended the validation workshop.

Barrier’s, facilitators, resources, and strategies for normalising USS

Participants identified several facilitators considered important for scaling up and normalizing USS in routine ANC as reflected in Fig. 5.

Facilitators to scaling up and normalising USS in routine ANC

Clients and community sensitisation

Most participants asserted that increasing awareness among clients and communities through multiple channels such as involving local leaders and health professional is essential for optimising the uptake of USS in routine antenatal care. A midwife from Blantyre emphasized the significance of health education, stating that educating both clients and communities is a prerequisite for scaling up USS in routine antenatal care.

“[For] community sensitization, we can involve chiefs and HSAs [Health Surveillance assistants]. And we can also have posters. Health education about USS at ANC can motivate people”. (Midwife - Blantyre workshop)

Task sharing and allocation

Midwives that have been trained and have had experience providing USS emphasized the importance of structured planning, teamwork, and accountability as enablers in the delivery of services. One midwife shared a pivotal insight into the practical steps that have facilitated the program’s success to emulate from during normalisation process.

“The first thing that has really helped us to facilitate this program was that after the training we had to sit down and make task allocation because we provide other services besides antenatal clinic; we do other things, so we formulated a roster for USS. To ensure accountability in the provision of ultrasound scanning services, a hardcopy register is maintained. The individual responsible for conducting the scans is required to document each instance of service provision in this register. Subsequently, facility leadership reviews the entries to verify that the designated personnel fulfilled their assigned duties. And we appointed a person to remind us of instances when there is no midwife in the scanning room. As such, we have two members of staff who remind midwives to be available, and if one does not come, they follow up.” (Midwife - Lilongwe Workshop).

Some participants observed that positive relationships among staff are required for effective group collaboration in normalising USS in routine ANC.

“There must be teamwork, and services should not be delayed when the ward in-charge is not there… and we should know that all nurses will not be trained on ultrasound scanning …… such that in other instance the midwife competent in USS [allocated other tasks], may also be conducting ANC…. that’s where the teamwork is needed.“(Midwife - Blantyre workshop).

Participants emphasised that there is a need to embrace a team approach in the delivery of ANC as opposed to an individual to accelerate the normalisation of USS services in routine ANC.

“Like every activity that happens at our health facility’ it requires everyone to play a role because one individual cannot manage to do this on his/her own.” (Midwife - Lilongwe workshop).

Alongside effective teamwork, participants reiterated that ANC services should be efficiently organised to ensure that all women receive the necessary ANC services, one midwife emphasised.

“We can start with this…The issue about roster is very important, it helps to bring order…at least scanning should be happening, like for some of us who provide the service (antenatal care) on specific days, there is need to ensure that on such days all pregnant women should have access to the service” (Midwife – Lilongwe workshop).

Integrated theme: resources and political will

Some factors, particularly resource availability and political will, were identified as context-dependent, functioning as facilitators when present, barriers when absent, and as strategic levers when deliberately mobilised. These contextual factors would influence the implementation and sustainability of the USS normalisation programme. These are therefore discussed as integrated themes.

Political will

Participants repeatedly mentioned in their discussion groups that political will is critical in all spheres of USS normalisation. Participants described political will as having support from high offices of the Reproductive Health Directorate in the Ministry of Health leadership and partners cascading down to District and facility management teams to implement and sustain the USS normalisation programme.

“Yaah, that is true, even for sustainability, it will need political will from MoH [Ministry of health] and RHD [Reproductive Health Directorate] and that will trickle down to the councils.” (Midwife - Blantyre workshop).

Participants asserted that intervention might be sustained by providing resources, supervision, and mentorship. Supervision by the leadership creates avenues for sharing new information when available and it authenticates the programme being implemented.

“Yes, because if the supervision is not done, the staff will consider this invalid by saying the work is not being supervised. But supervision is of good help as new information may be coming in for the updates.” (Midwife – Blantyre workshop).

Resource availability

Most participants pointed out that resources are critical to implementing an innovation. Resources encompass both human and material assets, including infrastructure, power backup, skilled midwives, and reference materials.

Reliable power supply

Almost all participants in all sites expressed concerned with intermittent delivery of USS services due to power interruptions and advocated for power backup

“Power backup for the scanners; sometimes we have blackouts three times a day. You find that someone has gone there to do scanning, and there is a power cut, and the battery is empty.” (Midwife - Lilongwe workshop).

Most participants advocated for the provision of power backup to mitigate unforeseen power outages during service delivery

“Back-up power like a bigger genset [is required] (midwife – Lilongwe workshop).

Availability of trained midwives and training materials

A Few participants emphasised that, to improve USS and normalise the service, more USS-trained midwives are needed.

“Trained personnel should be number one because if we have scanning machines alone imagine with no trained personnel then it won’t work” (Midwife - Blantyre workshop).

To sustain midwives’ USS skill, several participants indicated that a manual is necessary, as it serves as a reference resource.

“A manual is also needed, for reference purposes” (Midwife – Blantyre workshop).

Space

Participants from across the facilities expressed a concern that it may be difficult to scale up USS due to shortage of rooms in many health care facilities. Participants said that it is not uncommon that the same room used for USS, is also used for other services which inadvertently compromising both physical and verbal privacy.

“The room we use for scanning, we got the one used for “ANC palpations” that means we caused shortage in terms of space, and we compromised privacy for that other side because it now means they are using one room which has two beds”. (Midwife - Lilongwe workshop)

Likewise, one Mzuzu based participant challenged the status quo in facilities and stressed that infrastructure is a central challenge to provision of care in health facilities and should be presented as a key issue. She said,

“I think that issue comes under infrastructure. It must stand out because this is our biggest challenge as well.” (Midwife- Mzuzu workshop).

Barriers to scale up and normalising USS in routine ANC

The discussion on barriers to normalisation for USS in routine ANC, encompassed various aspects related to both Providers and patients.

Patient related barriers

Beliefs and misconceptions

Participants said that some pregnant women believe that USS is associated with adverse effects on the unborn baby. Women fear that scanning rays can harm the unborn baby. This midwife said,

“Cultural beliefs for instance, others believe that if you do a scan [USS] the rays can harm the baby, it disturbs development of the fetus. (Midwife - Blantyre workshop)

Unmet expectations

Owing to the limitations in the scope of training that midwives receive that omitted aspects like determining sex of the baby, participants stated of having some unmet expectations from pregnant women.

Sex of baby

A few participants mentioned that women are willing to have USS, but their perceived needs for having USS are not met especially in instances where determination of the baby’s sex is not done and they further stated that such limitations reflect badly on the provider. Participants highlighted that the limited scope of USS service provided results in pregnant women feeling underserviced because they cannot know the sex of the baby apart from gestational age determination.

“Ok we can say the woman is dissatisfied, so dissatisfaction of the client is an experience for you that you are providing the service, but someone is not satisfied because one aspect of their expectation …despite that you explain to them, but the [woman] had set what she wanted when coming, so the expectation of most women on sex of the baby is not met, so that’s a negative experience”. (Midwife - Mzuzu workshop)

Exclusion due to gestational age

Some participants raised a concern that the recommended gestational age of USS, which is before 24 weeks, excludes early pregnancies. This exclusion from getting a USS frustrates women and leads to unintended beliefs that they need to initiate ANC in the second and not first trimester.

“I agree with this point [Rescheduling pregnant women with unpalpable fundus without providing USS services] that they [pregnant women] get disappointed. Pregnant women state that we [health workers] advise them to initiate antenatal care early and when they have initiated the services, health workers tell them that they cannot conduct an USS. As such, it is like we want them to come in second trimester. It is like we are contradicting ourselves” (Midwife – Lilongwe workshop).

According to some participants, it is also typical for women to miss the scanning phase if they report after 24 weeks. Because of this, many women attend ANC services without having the chance to be screened, which leaves them feeling helpless.

“Now for those that come with a gestation age of 28 or 29 weeks or above, we are not scanning them, and they perceive it as a lack of attention from the midwives, since we are only targeting those who are 24 weeks. (Midwife – Blantyre workshop)

One participant said that women feel left out when they come in late stages of pregnancy, yet USS is critical to determine their expected date of delivery.

“… for women coming in late pregnancy, they feel left out, because some of them don’t know their EDD [expected date of delivery], so they wish that though it’s late they should be scanned to know when they are delivering” (Midwife - Mzuzu workshop).

Provider related barriers

Work overload

Participants stated that midwives are faced with work overload with the addition of USS to their scope. They further stated that their work extends beyond ANC services, and they must deliver other services as well. The barrier of workload is compounded with the fact that only very few providers are trained in conducting USS thereby making it difficult to scan a huge number of willing women.

“The challenge could be increased workload. Us being a facility that is already implementing this, we have experienced increased workload as a challenge, and the root cause of increased workload could be: Increased number of women attending ANC at our health facility- in other words “people” (Midwife - Blantyre workshop).

Strategies for scaling up and normalising USS in routine Ante natal care

Participants proposed various strategies for accelerating normalisation of USS in routine ANC services including capacity building to increase USS skilled staff to manage the growing numbers of eligible women, provide infrastructure for clients and provider to optimise their comfort during service provision, leadership involvement for guidance, support, resource provision and raising community confidence in using the USS and ANC service.

Capacity building

Pre - service and on-the-job training

Most participants prioritized pre-service training as an important strategy to build foundational knowledge on USS for health care professional including nurses and clinicians to meet the impending demand and to sustain the service. Additionally, on-the-job training for other professionals in the health sector is required to address the immediate need of USS skilled staff and foster teamwork.

‘They should be incorporate USS training in the curriculum so that the health workers are already trained while in school… Not just [train] nurses, but also clinicians, midwives, and those in private should be taken on board in the training and mentorship.” (Midwife - Mzuzu workshop).

Improved infrastructure

Participants highlighted the need to improve facility infrastructure to accommodate USS services. Most participants urged that the facilities should have adequate space within the maternity department to reduce movements of women around the facility in search of USS room. Some participants suggested acquiring tents for outreach clinics, under which USS services can be provided.

“On service delivery, if the infrastructure is not there, then it can also pose a challenge to service delivery.” It [USS services] should also be in the same maternity wing under one roof. Within reach, so that people should not walk a long distance around the facility, or in the ANC block or ANC room. Tents could be used for outreach activities or at the facility as a waiting room to reduce congestion at the antenatal department.” (Midwife - Mzuzu workshop).

Community sensitization

Participants proposed that the communities and target population of the service be made aware of USS services because that is key to accessing the service. Participants further said that sensitization of the community is critical for scale-up interventions and asserted that through sensitization, local leaders and communities would know the importance of USS during the ANC.

“The first thing is sensitization; the people should accept the initiative. After that, the midwives should be made available, and a couple of them should be added to the existing staff. (Midwife- Lilongwe Workshop)

Integration of USS into other services

Participants suggested that USS services be integrated into other routine health care services to speed and increase the uptake and normalize the provision of the services.

“They should try to integrate the services; they should not look parallel… They should integrate the scanning service into the other services. For example, you would see one just coming to work solely to do scanning. Do we need to incorporate this information into the DHIS tool? This is also part of the activity for us.” (Midwife – Lilongwe workshop).

Developing and standardisation of the training manual

Most participant stressed the importance of standardising the training because different models of scanning machines are coming out. It is important to have uniformity so the USS service for women is equitable.

“So it’s like for us, there is a certain group that has been trained last week which means we will be doing different things at the same facility because they will find me, I do what I know and they go to someone else will also do what they know which is contradicting ourselves… that’s what someone was asking…I think the content should be similar to all of us so that we are on the same platform. Not that everyone else is doing what they know…(Midwife - Blantyre workshop).

Participants emphasise the need to a standardised training regardless of where and who trained them. This midwife explained,

“Yes, there should be uniformity despite that you have been trained with different bodies, but the content should be the same for easy implementation.” (Midwife - Blantyre workshop).

What to include in the manual

Responding to the question on what needs to be included in the manual, two themes emerged: what to include and the outlook of the training manual. Participants proposed that the manual should include Contents related to the machine, scanning procedure and human anatomy.

Characteristics of the manual

Manual outlook

Some midwives proposed to have the manual cover page with a picture of the Malawian midwife to show that it is a manual used at local level and by Malawian Midwives.

“They shouldn’t put a picture of a white midwife but a Malawian, the one working on the ground from a health Centre, not someone from a tertiary facility” (Midwife - Blantyre workshop).

Another participant described how the picture should look like on the manual as follows.

“Our priority was the cover page. On the cover page, we suggest that there should be a midwife doing scanning so that when people just look at the manual, they should immediately know what is inside the manual. That was our priority! - because the moment one holds the manual, just looking at the picture, he or she will have an idea of what is expected inside.” (Midwife - Mzuzu workshop).

Parts of USS machines

Participants suggested to include parts of the machines to ensure proper use and care.

“They [midwives] should also know the parts of the ultrasound machine and the use of each part. For example, this part is for freezing…“Parts and use of the machine, Functions of the parts of the machine. Showing the different uses of the parts like freezing, then we can add care. should it come at the end or now? I think the care can come now” (Midwife - Blantyre workshop).

Participants added that apart from knowing the parts of the machines, it should have both theoretical and practical sections on how and when to use the machine. The participants proposed the manual needs to have some narration and practical guidance on how to handle the machines and how to use it.

““I think for me; this manual should have both the theoretical part of how to do the scanning and the practical part and some references when someone is doing the scanning… so this manual should have the theoretical chapters and practical part references.” (Midwife – Blantyre workshop).

Woman and fetal anatomy

When participants discussed regarding accuracy when conducting USS, participants proposed to include anatomical features of the woman and fetus to facilitates accurate identification of Fetal parts during scanning. This midwife said:

“It [the training manual] should have a content of the anatomy and physiology of a woman, fetus, USS machine parts, functionality on how to use videos, pictures, checklists and procedures.” (Midwife – Mzuzu workshop).

Competency checklist

Participants suggested to include a competence or and assessment checklist to assess the level of understanding when training and orienting midwives to USS.

“Out of the manual we should also have a checklist of assessing the person to see how much they have learnt. This is because we cannot carry the manual all over so we have to extract something from the manual like a checklist” (Midwife - Blantyre workshop).

User friendly

Majority of participants expressed preferences to have a training manual that is easy to use. The participants hinted that the manual should be attractive, lighter and user friendly to encourage providers to use it.

“I think the manual should be a portable one, thus easy to handle, appealing colour of shade …. Yes, something appealing so that the person chooses something appealing to see what is inside… attractive.” (Midwife – Blantyre workshop).

New and previously used versions of the training manuals

Following participants feedback, a revised training manual was developed featuring an updated cover page Fig. 6 compared with the previous version Fig. 7 and the revised table of contents Fig. 8 compared with the earlier manual Fig. 9.

Fig. 6.

Front page of the newly developed training manual

Fig. 7.

Front page of the previously used training manual

Fig. 8.

Table of content of the new training manual

Fig. 9.

Table of content of the previously used training manual

Discussion

Our study aimed at assessing perceptions of health care workers, identify challenges, facilitators and explore strategies to scale up and normalize USS in routine ANC. Additionally, we aimed at co-creating a training manual to support a successful scale up and normalisation of USS in routine ANC. The facilitators and strategies included strong political will, availability of infrastructure such as private rooms and electricity, presence of trained USS staff, service integration including service restructuring and staff reallocation, and community sensitization. The barriers include lack of trained midwives, lack of infrastructure and Electricity outages, negative beliefs, and misconceptions about USS. These findings are similar to the existing evidence on literature that explored enablers and barriers to USS in LMIC [31–33]. The limited number of trained staff can be explained by the fact that traditionally, USS has never been included in the nursing and midwifery’ scope of practice nor a component of pre- service training in the nursing syllabus. However, the ongoing introduction of USS training is expected to expand midwives’ competencies, increase the pool of skilled practitioners, and strengthen service delivery capacity. in low resource settings.

The barrier of work overload coupled with shortage of staff was one of our major findings in providers related challenge. Despite Midwives being enthusiastic in providing USS, their limited number at a facility would be overpowered by the large number of motivated women seeking USS services [34]. It is not uncommon in LMIC to have limited trained midwives at health centres [primary health care facilities] leading to high workload as they may have other services to provide apart from ultrasound scan services [35]. These findings are in line with findings reported by Roro et al. (2022) from a study that explored barriers and facilitators for the introduction of USS in primary health care facilities in Ethiopia which revealed that a high levels of motivated women wanting to receive USS service against few trained staff who intern may be transferred or absent from work lead to work overload for the remaining staff at the facility [32]. Similar findings were reported from Rwanda where shortage of staff irrespective of the availability of USS machines was a major constraint in the provision of the service [36].

Our findings on lack of infrastructure including ultrasound private rooms were also reported in a study conducted in rural settings of Democratic Republic of Congo [37] and in low and middle income countries [37, 38]). Alongside good infrastructure, there is a need for structural changes within health systems to accommodate ultrasound interventions such as use of wireless mobile devices (mHealth) [39]. These modern mHealth technologies are portable and would be beneficial to Malawi to reach hard to reach areas such that, every pregnant woman would benefit from the services.

Our findings on electrical power interruption are consistent with findings by Swanson et al., (2017), who reported that electricity is a notable constraint to USS service provision in low income countries [37]. The World bank (2024) reported that 600 million people in LMIC lack sustained power supply while one billion people are served by health care facilities with intermittent or no power supply in LMIC [40, 41]. Electricity is essential for powering medical care, and devices, including Ultrasound Machines [40]. In Malawi, most health facilities rely on one electricity grid, the Electricity supply commission of Malawi (ESCOM) [41]. The power supply is erratic with some health facilities experiencing long hours of black outs. Although alternative sources of power such as solar power are emerging and available, they are not widely installed in health care facilities. An earlier study in DRC stressed the importance for a constant power supply and sourcing alternative power supply as a backup [37]. Constant power supply is pivotal for sustaining the service and prevents rescheduling clients who may not return due to distance or financial constraints leading to missed opportunity for a scan within the period [36, 37].

Patient related barriers encompassed beliefs, misconceptions, and unmet expectations of USS service. This finding can be attributed to lack of knowledge on the timepoint when an USS can be conducted as well as its functionality. Studies that explored the origin of misconception in science and medicine asserted that lack of information and familiarity to scientific knowledge, are the basis of misconception and misinterpretation of events [42, 43]. Additionally, other studies have attributed beliefs and misconceptions surrounding obstetric ultrasound to women’s fears of potential harm to the baby and overestimation of the scan’s capabilities [44, 45]. These misconceptions are further compounded by inadequate counselling before the procedure, which can result into women’s limited understanding of USS, its purpose, capabilities and limitations, leading to unrealistic expectations [40]. Building awareness in communities and developing a robust counselling process should be a prerequisite when introducing, adopting and normalising USS in routine ANC to minimise misconceptions and unrealistic demands [44, 46].

The availability of USS trained midwives at both primary and secondary levels of care, supported by standardised staff training programs enhances service delivery [47]. Acquisition of knowledge and skill in obstetric Ultrasound scanning and increasing numbers of trained staff can be achieved through appropriate training programs [48]. In Malawi, standard diploma and degree programmes for nurses and midwives provide core midwifery competencies but do not include obstetric ultrasound training. However, recent evidence demonstrates that midwives with no prior ultrasound experience can effectively be trained to perfume obstetric ultrasound [25, 47–49]. Discussions are underway amongst stakeholders including researchers, Ministry of health and regulators to consider integrating routine USS training for midwives in health care system and the pre-service training service. Introducing both pre-service and on the job USS training has the potential to enhance skill and competencies in students and existing staff already in practice to sustain the service in care systems. The on-the-job USS training strategy would increase the number of qualified professionals, to better meet the rising demand of USS and ensure sustained scale up and normalisation of USS into ANC services [49, 50].

Our findings on the need to integrate ultrasound services (USS) into other health services contrast with those of Swamson et al. (2017) who highlighted potential logistical challenges including the need for substantial resources, ongoing training, and timely repair of equipment as barriers to sustaining ultrasound programs over time that need to be addressed when integrating USS, leading to register a doubt if scaling up of USS should be warranted [37]. Although USS service integration studies on USS in routine ANC are limited, other maternal and neonatal care integrated services have been successfully implemented with positive results. For instance, in Malawi, the Maternal and neonatal health and HIV/AIDS service integration took centre stage in the HIV era to include HIV testing and care for the prevention of mother to child transmission of HIV (PMTCT) [51]. The integration was successfully implemented in routine ANC, labour and delivery and postnatal care services and is still ongoing [50, 52]. Our findings suggest that integration would be a strategic and effective method of promoting USS, offering multiple entry points for scanning pregnant women during ANC and labour and delivery [53]. Although the cost of integration varies across different settings, many studies have shown that integration would be less costly and the approach has the potential of improving providers coordination, thereby enhancing accessibility and efficiency of the service to making ultrasound scanning routine and indispensable part of maternal and neonatal healthcare [53, 54].

Our finding on having dedicated private rooms that ensure privacy, security, and good ventilation, mirror Borne et al. (2017) recommendations on the availability of separate rooms located within the gynaecology ward to provide comfort to both clients and providers and reduce client movement seeking USS elsewhere [55].

To introduce the service and raise awareness about USS to the public, community sensitization remains pivotal in scaling and normalising of USS. Community sensitization is an effective tool in providing first-hand, reliable information to communities as the information gets to the targeted audience and influential people [56]. Community sensitisation with messages that clearly explain the benefits and safety of ultrasound scanning as highlighted in this study, and has potential of increasing service utilisation [57, 58]. The involvement of local leaders as custodians of culture and community norms, hold significant influence over larger communities, and their support is crucial in persuading communities to accept and utilize USS services and dispel rumours and misconceptions [59]. Our findings on community sensitization cements what was earlier reported in Margolies et al 2017, that local leaders such as village chief plays the principal role in establishing and maintaining norms as well as in decision-making for social support [60] Notably local leaders play a role in supporting Maternal Neonatal and Child Health (MNCH) service utilization by women [61].

Political commitment illustrated in the form of leadership support and the provision of oversight of the programs has potential to effectively and efficiently scaling USS in routine ANC [62]. Furthermore, WHO proposes that management teams are central to allocation of resources to facilities, provision of regular supervision and mentorship, and sharing of new knowledge when available to enhance quality of care and motivate staff. Implementing health care programmes largely depends on the capacity and commitments of facility leadership [63].

The call for a standardised training manual for midwives builds upon earlier findings from Rwanda that confirmed lack of standard clinical guidelines for the use of obstetric ultrasound in health care systems trainings [64]. The standardised manual would guarantee uniformity while reinforcing provider’s adherence to recommended USS standards thereby preventing misuse of ultrasound scanning [55] Additionally, the standardised manual would address heterogenicity in training and care provision. Matschl et al. (2024) confirmed the existence of varying approaches to trainings, concepts and programs with some meeting substandard against the international guidelines, such as the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) calling for guidelines and curricula for standardized training [65, 66]. Additionally improving manual content, and outlooks would enhance the use of the manual. A well-developed manual with summaries of technical information written in a manner that makes them accessible and ready for use in clinical practice while, conforming with contextual issues in this case Malawi, are recommended [64, 67].

Strength of the study

The key strength of the study was the use of participatory workshops which promotes collaboration and inclusivity and ensures that the outcomes are supported and implemented. The insight shared by participants during the workshops were particularly valuable as, some providers had lived experience of USS service implementation that enabled them to identify gaps to resolve as they prepare for scaling up and normalising USS services. In addition, the study involved a diverse group of health professionals including frontline staff, regulators, academics, and policy makers. This ensures that the programme is relevant, in line with national research agenda and beneficial to the public. As a results, it is more likely to get approval to be rolled out and be sustainable within the health care system.

Limitation

The limitation of the study relates to interactive nature of walkthrough method which emphasised corrective sense making. As a result, some contributions reflected engagement with others’ ideas rather than detailed articulation of individual perspectives, potentially constraining the depth of individual-level explanations. However, the group discussions generated meaningful and contextually relevant ideas that informed the study findings.

Implications

USS training among midwives requires standardisation by having a training manual to ensure uniform competencies, safe practice, and effective task sharing. There is a need to enhance the inclusion of USS training the preservice modules so that we achieve a critical mass of midwives competent in USS. While broadening scopes of practice may strengthen service delivery, particularly in resource-constrained settings, such changes require alignment, regulatory frameworks, and training systems. While enhanced care delivery and management responsibilities may not necessarily warrant immediate changes in remuneration, they may have implications for workload, accountability, and performance expectations. Once expanded roles become formalised, integration into pre-service training curricula may be necessary to ensure competency and reduce reliance on in-service or ad hoc training.

Conclusion

Scaling up of ultrasound is possible in Malawi. This requires proactively addressing documented barriers and leveraging facilitators to ensure successful implementation. Ensuring adequate resources, political support, and community education are critical steps toward achieving this goal. The existence of a standardised training manual will support continuous staff training and serve as a reference point for review, refreshing knowledge and reinforcement. By overcoming the identified challenges, ultrasound scanning can become a normalized part of antenatal care.

Authors’ contributions

CK, LG, DL and ALNM conceptualised the project. DL, LG, and ALNM supervised the project. DL and ALNM acquired funding. BM, CB, LM, AK, DL, LG, MC, NM and ALNM planned the project, developed methods and discussion guides. LM, CK, BM, CB, AK, LG, AM and ALNM facilitated workshop discussions. CK, CB, and AK transcribed the data. BM and ALNM developed the analysis plan. BM performed formal data analysis. BM drafted the manuscript, DL and ALNM critically reviewed the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

This study was funded by the NIHR through the DIPLOMATIC grant, Ref:17/63/08. The team is also supported by the NIHR through the SAFE Motherhood (grant 134781) Global health research group and NIHR Professorship NIHR300808. All this is UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not those of any of the funders.

Data availability

Data and related materials for this work are available upon reasonable requests to the author.

Declarations

Consent for publication

Verbal consent was obtained from participants for the use of any photographs included in this manuscript. Written informed consent was obtained from all participants for participation in data collection. All data is presented in anonymised form.

Competing interests

The authors declare no competing interests.