Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 2 Issue: 3

Obstetrical Ultrasound in Senegal: Knowledge, Attitude and Practice

Philippe Marc Moreira, Mamour Guèye*, Marie Edouard Faye Diémé, Magatte Mbaye, Serigne Modou Kane Guèye, Odette Daba Sarr and Jean Charles Moreau
Clinique Gynécologique et Obstétricale, EPS Aristide Le Dantec, 3, Avenue Pasteur BP 3001, Dakar, Sénégal
Corresponding author : Mamour Gueye
Clinique Gynécologique et Obstétricale, EPS Aristide Le Dantec, 3, Avenue Pasteur BP 3001, Dakar, Sénégal
Tel: 00221 776517272
E-mail: [email protected]
Received: January 06, 2013 Accepted: March 02, 2013 Published: March 08, 2013
Citation: Moreira PM, Guèye M, Faye Diémé ME, Mbaye M, Kane Guèye SM, et al. (2013) Obstetrical Ultrasound in Senegal: Knowledge, Attitude and Practice. J Womens Health, Issues Care 2:3. doi:10.4172/2325-9795.1000107

Abstract

Objectives: Identify the profile of providers, determine their level of knowledge of protocols and standards in obstetric ultrasound, assess the attitude and quality of the relationship provider-patient, assess the quality of ultrasound examinations and identify the need for continuing medical education in obstetric ultrasound.
Materials and methods: This is a prospective study over a period of four months from January 1, 2009 to May 31, 2009, targeting providers practicing obstetrical ultrasound and officiating in the regions of Dakar and Thies. The parameters studied were socio professional characteristics, training received, knowledge of norms and standards in obstetric ultrasound, the attitude during the ultrasound examination, the level of practice of obstetric ultrasound, the standards and obstetrical ultrasound protocols and training in obstetrical ultrasound. Data were analyzed using the software Sphinx.
Results: The rate of acceptance was 76.2%. Gynecologists (59.4%) and radiologists (25%) were most represented in our sample. The ultrasound machine used was up to 10 years old or more in 70.1% of cases. The recommended frequency array of abdominal probe was known by 71.9% and 40.4% for the transvaginal probe. The recommended number of fetal ultrasound during normal pregnancy were known by 84.5% of operators and their frequency by 72.9%, 83.3% knew the criteria for fetal biometry and 44.4% of fetal morphology.
Conclusion: The legal framework for the practice of ultrasound is urgent to prevent further abuses and increase the quality of exams. There is urgent need for standardized basic training, certification and periodic recertification based on continuing medical education for providers in our country.

Keywords: Ultrasound; Obstetric; Dakar; Knowledge; Attitude; Training

Keywords

Ultrasound; Obstetric; Dakar; Knowledge; Attitude; Training

Introduction

Obstetrical ultrasound is essential at all stages of pregnancy monitoring, by providing a considerable amount of information on the morphology and fetal physiology However, the legislative framework limited to the nomenclature of medical acts, gave free rein to initiatives by professionals [1]. In Africa, ultrasound was mainly developed in the field of fetal biometry [1,2]. In Senegal, as elsewhere, interest in this examination has increased its offer, and is spreading more and more. But the Senegalese health system does not have data to know exactly the current practice of obstetric ultrasound. There are no specific recommendations, in relation to the standards and protocols in obstetric ultrasound. We conducted this study in order to evaluate the practice of obstetric ultrasound in our country. The objectives of this study were to: identify the profile of providers who practice obstetric ultrasound, determine their level of knowledge of protocols and standards in obstetric ultrasound, appreciate the attitude and the quality of the provider-patient relationship during fetal ultrasonography, assess the quality of routine ultrasound examinations according to certain standards, and identify needs for continuing medical education providers in obstetric ultrasound.

Materials and Methods

This was a prospective study conducted over four month from January 1 to May 31, 2009, with a survey through interviews using a semi-structured questionnaire with open or closed questions, single or multiple-choice. The questionnaire was administered by an investigator. The interviews lasted an average of forty (40) minutes: were included in the study providers practicing obstetrical ultrasound (gynecologists, radiologists, general practitioners, midwives or others), officiating in Dakar and Thies in the private, and/or public sector who agreed to participate in the study. Physicians were selected using a database of practicing physicians. The parameters studied were the socioprofessional data, training received, knowledge of norms and standards in obstetric ultrasound, attitude during the ultrasound examination, the level of practice of obstetric ultrasound, the standards and obstetrical ultrasound protocols and training in obstetrical ultrasound. Data were analyzed using the software Sphinx.

Results

We submitted the questionnaire to 126 obstetric ultrasound providers, 96 accepted. The acceptance rate was 76.2%.
Socioprofessional characteristics
Of the 96 recipients, 65.6% were men and 34.6% women. 41% were aged under 40 years, 31% were aged between 40 and 50 years, 19% between 50 and 60 years and 5% were older than 60 years. Ultrasounds were performed by gynecologists in 59.4% (57/96) and radiologists in 25% of cases (24/96). Other providers were represented by general practitioners (GPs), surgeons and paramedical. The majority of providers interviewed (61.5%) had received their diplomas on their speciality for over 10 years, and among them, 31.3% worked for over 20 years. Thirty-three percent (33.3%) were graduates in ultrasound (general or obstetric), whereas 66.7% practiced sonography without a diploma.
Knowledge
Nearly 30% of providers did not know the age of their ultrasound machine, 18.8% had more than 10 years of use. Among the devices used, 97.9% had an abdominal probe, 91.7% had a transvaginal probe and 57.3% a linear probe. These devices were equipped with a movement time mode (TM) in 95.8% and an 88.5%, a Doppler mode. The level of knowledge of technical features and some norms and standards of fetal ultrasound are listed in table 1.
Table 1: Knowledge provider relating to characteristics of ultrasound transducers and norms and standards.
Attitude
One provider out of 3 (35.5%) claimed to be on time for consultations ultrasound, while 64.6% of providers reported being late. During the ultrasound examination, 63.5% accepted one companion, 10.4% accepted two, 21.9% did not accept a companion and 4.2% were indifferent to their number. If the opportunity arose, 43.8% of physicians agreed with a multimedia recording if the patient asked. Before starting the ultrasound examination, 18.8% of providers let the patient sit directly on the ultrasound table without questioning her antecedents and the course of pregnancy.
During the ultrasound examination, 53.1% of providers alternated periods of silence and comment periods, while 37.5% commented on the conduct of the examination. On the announcement of fetal sex, most of the respondents (65.6%) asked the patient if she wanted to know the sex of the fetus before announcing, 26% expected that the patient’s request, 4.2% refused to say and 4.2% said the sex systematically.
Use of ultrasound
A proportion of 76.2% of providers were practicing ultrasound for over 5 years. Obstetrical ultrasound accounted for more than 50% in their ultrasound practice. A proportion of 19.8% performed less than ten scans per week, 36.5% realized an average of 18 per week, 20.8% realized 38 per week, and 14 6% realized over fifty weekly ultrasounds.
In the first trimester of pregnancy, 83.3% of providers routinely measured crown-rump length (CRL). In the second trimester, 88.5% were conducting a routine morphological examination. As for fetal biometry, 39.7% of providers knew the landmarks of the biparietal diameter and 45.7% knew all the landmarks of transverse abdominal diameter. The announcement of the results of the ultrasound examination was oral in 68.7% of cases and written in 49% of cases. The majority of providers (59.4%) used the stereotyped obstetric ultrasound report of the French National College of Obstetricians and Gynaecologists (CNGOF). The inclusion of biometric measurements on images referenced in the report was done by 14.6% of providers. Biparietal diameter (BIP), femur length (FL), and abdominal circumference (AC) were attached to the ultrasound report by 27.4% of providers. A digital recording of the ultrasound examination was given to patients by 9.4% of practitioners.
Training
Among the providers interviewed, 97.9% thought that the practice of obstetric ultrasound should be allowed to gynecologists, 79.2% to radiologists, 39.6% to GPs, 64.6% to midwives and 5.2% to nurses.
Almost half of the providers (47.9%) felt that midwives should be allowed to register for university degrees ultrasound in obstetrics and gynecology, and 52.1% were agree for other obstetric ultrasound training for midwives. The majority of providers (93.8%) would benefit from continuing medical education in obstetric ultrasound. They felt the need to upgrade the level of practionners to improve the quality of services. They also felt that the training was mandatory in any medical practice, as it would allow them to interact with other practitioners.

Discussion

In Senegal, the majority of fetal ultrasound (74.4%) is performed by gynecologists and radiologists, while in Hungary, nearly 100% of physicians who perform fetal ultrasounds, are gynecologists [3]. The radiologist is trained in imaging, but he lacks obstetric basics to interpret the information obtained from the analysis. The obstetrician is trained in obstetrical knowledge, but often lack formal training necessary to optimize images [3]. In Senegal, there is no legislation that allows midwives to perform obstetric ultrasound, while in France since 1986, the Code of Ethics for Midwives, allows them ultrasound fetal monitoring [4]. In our study, the majority of practitioners officiated in the public sector and without qualification. The diploma course that does not exist in Senegal before 2006 represented an obstacle for physicians who had not the opportunity to enroll in a University Diploma ultrasound in other countries, and promoted the use of ultrasound midwifery without a diploma.
The quality of ultrasound is an essential element of the reliability of the examination. In France, the Technical Committee of Ultrasound [5] has retained in its report in 2005, the following criteria: ultrasound machine less than 7 years with pulsed Doppler, and a cine-loop capacity at least 200 images of at least two probes (one transvaginal probe), and a maintenance log. It should be added that the ultrasound must be equipped with a control pedal gel image (freeze), freeing both hands for manipulating the probe and the fetus. In our study, nearly 30% of providers do not even know the age of their ultrasound machine. Nisand [6] and Pasquet [7] highlighted that technical change was such that 7 years certainly represented the usage limit, and 10 years obsolescence. In Senegal, there is no legislation controlling the ultrasound equipment, which can legitimately install the doubt in the reliability of exams.
A significant proportion of our sample experienced less than five years in the practice of obstetric ultrasound (39.6%); more than a third had an experience of over ten years. To 52.2% of providers, obstetrical ultrasound was more than 50% in their ultrasound practice. This predominance of obstetrical ultrasound could be explained by two reasons: the proportion of gynecologists and midwives in our sample, and the high demand for obstetric ultrasound. In addition, for those who have responded to this question, the level of use of ultrasound as three trimesters of pregnancy is equivalent (30.1% of first trimester ultrasound, 30.7% in the second trimester and 35.9% in the third trimester). These results appear to be inconsistent with the coverage in antenatal clinics in Senegal that are most important to the second and third trimesters, compared to the first trimester. Does that mean that the Senegalese pregnant in early pregnancy used more frequently ultrasound to clinical consultation? In all cases, the early use of ultrasound improves the dating of pregnancy in women who often do not retain the date of their last menstrual period.
The recommended number of ultrasound examinations during pregnancy monitoring was known by 84.5% of providers. In 1987, the French College of Obstetricians and Gynecologists had recommended two ultrasounds during normal pregnancy [8]. These recommendations have become obsolete, the percentage of pregnant women who had three or more ultrasounds during pregnancy increased from 27.8% in 1981 to 90.4% in 1995. To legalize this practice, the National Technical Committee of Prenatal Ultrasound Screening in accordance with the National Academy of Medicine and the French Agency for Sanitary Safety of Health Products, recommended in 2005, three systematic ultrasound examinations [6]: between 11 and 13 weeks of gestation and 6 days, between 20 and 25 weeks of gestation, and between 30 and 35 weeks gestation. In our survey, most providers knew the recommended number of ultrasound examinations during pregnancy monitoring (84.5%).
The number of ultrasound for a normal pregnancy is difficult to achieve in our socio-economic context, most providers recommended to limit the number of ultrasounds during pregnancy to two.
The minimum interval between two scans to monitor fetal growth was known by 44.8% providers. This situation can lead to inflation of ultrasound examinations or excessive delay in monitoring fetal biometry. The survey had identified deficiencies in both the level of equipment in the knowledge of certain standards and protocols in some fetal ultrasound. However, the value of ultrasonography depends on both the qualification and competence of the operators, and the quality of the material.
Regarding punctuality, it appears that 2/3 of sonographers arrived at the site after their patients. The survey conducted by Nicolas Friès in France in 2009 [9], revealed that 73% of sonographers arrived late in the consultation. In our context, this could be explained by overwork.
Practice of obstetric ultrasound is a medical procedure covered under the seal of confidentiality; it is up to the patient to accept the presence of a third party, in accordance with the operator. But in our survey, 22% refused a companion, and it was most often public sector providers. Working in the public sector can not justify the denial of accompanying, as in France, 100% of providers in all sectors, accepted one to four companions during the examination and 60% allowed children to attend the ultrasound [9]. Advocacy and awareness of medical staff in the public sector for better rights of clients should be pursued. It is true that the vision of the future child, made even more realistic by technological advances, fascinates the media, parents, and as professionals, it is also true that ultrasound during pregnancy is the first contact between the couple and the unborn child [10,11].
Our results show that communication of providers needs to be improved, 20.8% of providers were showing total silence unlike Friès data, where only 2% providers adopt this attitude [9]. Like any medical examination, the result of the ultrasound should always be communicated to the patient, but always remembering the limits of this radiological examination.
In France, the National Council of the College of Physicians [12] has made the training of operators of the criteria of quality and proposed protocols for upgrading under the auspices of learned societies. As well as the technical nomenclature and content of the exam, training of operators is one of the criteria for quality assurance in ultrasound.
In Senegal, until recently, the initial ultrasound existed only within the Graduate Diploma in Radiology and General Radiology only for students of the specialty. Ultrasound University diplomas were created in 2006. This explains why, among the participants in the survey, only 33.3% were graduates in ultrasound. A survey conducted in Texas in 1991 designed to compare the skill level of doctors in training, and experienced teachers in the fetal ultrasound showed that the quality of examinations was similar between doctors in training and faculty [13].
In Senegal, since 2003, with the support of the African Development Bank, 56 midwives were trained in ultrasound. Kongnyuy and van den Broek [14] in a work published in 2007 confirms the usefulness of this approach in low resource countries, where midwives must necessarily be involved in the provision of obstetrical ultrasound. Reflection is urgent because the need is urgent and demand increasingly high. This training must be supported by well-organized programs of regional and national quality certification services after training. Such certification shall include, in addition to the posttraining professionals, the definition of skill levels, accreditation of health facilities offering ultrasound, and the establishment of professional protocols. Together, these factors can ensure the quality of care and provide legal protection for practitioners [15]. Defining the objectives of the screening, the structure of the chain from the diagnostic screening, the development of a quality charter (including continuing medical education is a necessary component) will help to give a direction and content of continuing medical education.
Finally, a normative framework would monitor closely the practice of routine antenatal ultrasound to prevent possible abuse, leading to exploitation by health professionals for their own financial benefit in our resource-limited countries, as reported by Kongnyuy and van den Broek [14].

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