Quality and Utility of Third-trimester Ultrasounds at Kenyatta National Hospital; A Descriptive Cohort Study

Abstract

Objective: Quality ultrasonography is essential in determining obstetric care and outcomes. We evaluated the quality of ultrasounds performed at Kenyatta National Hospital (KNH) in 2019. We evaluated the clarity of indications for the ultrasounds (US), determined the adequacy of the US reports, quality of the images printed, the utility of the third trimester US in decision making, and the association between the third trimester US findings and obstetric outcomes. Design: This was a facility-based prospective descriptive cohort study conducted at KNH in 2019. Participants with the obstetric US at ≥28 weeks gestation were evaluated to determine study outcomes. Method: Pregnant women at ≥28 weeks gestation were screened, and those eligible were recruited. Consecutive sampling was applied to achieve the desired sample size. Study participants who delivered within the study period were assessed for selected perinatal outcomes. The indications for the US were compared with the World Health Organization (WHO) recommendations for developing countries. The adequacy of US reports was evaluated using Abuhamad et al. “writing an US report,” assessing whether the minimum mandatory parameters required were captured in the US reports. The quality of images printed was determined using the scoring criteria for quality of images by Salomon et al. with a cut-off of 67%. A change in management after the US report was available and the disposition made determined the utility of the US. Kappa statistic was used to compare the association between the US findings and obstetric outcomes. Data were collected using an electronic questionnaire from the patients' files, ultrasound reports, and printed images. A consultant radiologist, blinded to the participants’ clinical information, reviewed all images and reports. Statistical Package for Social Sciences software version 21 was used to analyze data. Results: 5400 participants were screened between August and December 2019. Two hundred thirty-nine (239) met the eligibility criteria, and 217 recruited. The mean age of participants was 29years, and a majority of the third-trimester pregnancies were term (39 -41weeks). 153(61.2%) US had a clear indication written on the request US form. Of the US reports, none captured 100% of the minimum mandatory data required in writing a third-trimester report. Only 58 (27%) scored above the required 67% cut-off mark for the quality of US images. 52 (24%) US influenced clinical management, with the most frequent change in management being an emergency cesarean section (63.5%). The association between the ultrasound diagnoses and obstetric outcomes was fair (K=0.61, p<0.001). Conclusions: There is a need to re-train on the correct prescription of the indications of US. The adequacy of reports and quality of images was generally low, contributing to the low utility of the US. There is a need for standardization training and recertification to ensure the adequacy of reports and quality of images, and improve utility in decision making, especially in this and similar settings in sub-Saharan Africa. Keywords: third-trimester ultrasound, Quality, decision making, effectiveness.