Dunya Tomic, Chief of Editorials and Publications PMSA
Ultrasound is a cardinal investigation in antenatal care that has become readily available in developed countries. The issues in implementing routine obstetric ultrasound in developing nations include limited resources, number of trained staff and lack of available maternity services to deal with implications of the ultrasound results. Amongst the Pacific, there is a great diversity both of culture and ethnicity, and also in levels of healthcare (1). This is reflected through the levels of skilled birth attendants (SBA) present at delivery amongst the various Pacific nations, which is generally a sound measure of level of perinatal care. According to recent research, in Polynesia, a high level of births (97.6%) were attended by SBA. Micronesia also had good presence of SBA during deliveries (93.9%) however Melanesia had inferior perinatal care in this domain, with only 61.2% of births being attended by SBA. The importance of SBA is highlighted by the perinatal mortality rates in these different regions, which stand at 13/1000 in Micronesia and 20/1000 in Polynesia, whereas Melanesia sees a much higher rate of 45/1000 (2).
Of course, there are other factors in addition to SBA that influence these figures. Antenatal care is a key factor in determining perinatal outcomes so these discrepancies in mortality rates should be taken into consideration when assessing the role and need for obstetric ultrasound.
To date, there has been scarce published literature regarding the number or skill level of ultrasound facilitators in the Pacific. In rural and remote Australia, there have been surveys conducted to determine the knowledge and training of ultrasound providers (3), and it will be crucial to obtain this information for the wider Pacific in order to plan future direction of obstetric services. One recent study (4) aimed to obtain this information from a sample of eleven Pacific countries. Ultrasound centres were identified through regional hospitals and facilitators were invited to complete self-administered written surveys. Surveys detailed the demographics, experience and workload of ultrasound operators, with scope for comments to be made regarding potential areas for improvement.
30 questionnaire results were obtained from 17 centres across the 11 countries. The countries surveyed were Kiribati, the Federated States of Micronesia, Papua New Guinea, Vanuatu, the Solomon Islands, Fiji, Tuvalu, Tonga, Cook Islands, American Samoa, and Niue. The average ultrasound experience of the responders was 7 years, and an overall 83% had formal qualifications in obstetric ultrasound (including radiographers, obstetricians, radiologists and physicians). The majority of training was undertaken in Fiji, Australia, New Zealand and Papua New Guinea. American Samoa had the highest mean level of experience (12 years), whereas Fiji had the highest number of trained (12) and certified (13) operators. The variability in ultrasound workload was significant, with 2 Fijian hospitals experiencing the highest volume of patients per month (2,000 patients per month). The major problems noted by ultrasound facilitators limiting their current practice were lack of knowledge, heavy workload and inadequate staffing, and faulty or limited equipment.
This study, the first of its kind from the Pacific, identified some of the gaps in obstetric ultrasound knowledge and training in the area. Globally, the vast majority of ultrasonography is performed by largely inexperienced individuals with minimal prior training (5). Although the levels of trained staff in some Pacific nations have reached sound levels, there are still significant gaps in knowledge as identified by the study; training as many facilitators as possible will be essential in improving health outcomes and minimising complications such as the perinatal mortality seen in the previously described figures. Suggestions made by the authors including practical training in more highly staffed countries, such as Australia and New Zealand, will probably be the best solution in the present day. When Internet becomes increasingly available across the wider Pacific, this may be a suitable and convenient platform for the future training of ultrasound operators.
1. World Health Organization 2006 Revision of World Population Prospects. http://esa.un.org/unpp/index.asp?panel=5
2. World Health Organization. Reproductive health indicators database. http://www.who.int/reproductive_indicators/alldata.asp
3. Glazebrook R. Manahan D. Chater AB. Educational needs of Australian rural and remote doctors for intermediate obstetric ultrasound and emergency medicine ultrasound. Canadian Journal of Rural Medicine. 2006;11(4):277-82.
4. Kodikara H, Mitchell J, Ekeroma A, Stone P. Evaluation of Pacific obstetric and gynaecological ultrasound scanning capabilities, personnel, equipment and workloads. N Z Med J. 2010;123(1327):58-67.
5. Glazebrook R, Manahan D, Chater AB. Evaluation of nine pilot obstetric ultrasound workshops for Australian rural and remote doctors. Rural and Remote Health. 2004. No 277.