OBJECTIVE: US is commonly used at antenatal care (ANC) in highincome countries (HIC) despite little evidence that it reduces maternal, fetal or neonatal mortality. In LMIC, US may increase ANC use and referrals for complications. We tested the hypothesis that US-naive providers could be trained to perform basic obstetric US and using these providers whether ANC and referrals would increase and result in improved outcomes. STUDY DESIGN: This intent-to-treat trial of 46,838 women and nearly 50,000 exams was performed in 58 clusters (geographic areas of >=350 births/year) in Pakistan, Kenya, Zambia, DRC and Guatemala. Clusters were randomized to usual care or to the intervention including basic US at 16-22 and 32-36 wks with referrals for USdiagnosed conditions. Fetal, neonatal, maternal mortality and maternal near-miss, the primary composite outcome, were collected during ANC, at delivery and 42 days post-partum through an independent registry. US exam data were collected on women who had a study US. RESULTS: Groups did not differ in use of ANC (RR 1.0 95% CI 1.00,1.01), the composite outcome (RR 1.09 95% CI 0.97,1.23), or the components (Table). After 2 wks of intensive training and a 3 mo pilot with all tests supervised, trainees performed quality basic exams. During the 18 mo trial, 78% of women delivering in the intervention clusters received at least 1 study US; 60% received 2. Conditions noted on US included twins, previa, oligo/polyhydramnios and abnormal lie. All were within expected ranges. 9% of women were referred for an US-diagnosed condition; 71% attended the referral. CONCLUSION: US-naive providers were successfully trained to conduct basic US exams. However, routine ANC US did not increase ANC use or hospital births nor did it improve the composite outcome or components. These LMIC results confirm Cochrane reviews of US in HIC. Introducing routine US in LMIC is unlikely to improve outcomes, would potentially pose a large burden on available resources, and detract from other more beneficial services.
Mcclure, E., Goldenberg, R., Swanson, D., Saleem, S., Esamai, F., Garces, A., … Nathan, R. (2017). 3: Routine antenatal ultrasound in low/middle income countries: a cluster randomized trial. American Journal of Obstetrics and Gynecology, 216(1), S3. https://doi.org/10.1016/j.ajog.2016.11.004