Leveraging Ultrasound for Maternal Health in Limited-Resource Settings

“In a world rife with healthcare disparities yet replete with innovation, there is no longer an excuse for the lack of diagnostic imaging in resource-limited settings. POCUS has changed the landscape.”

—Dr. Nahreen Ahmed
Division of Critical Care
University of Pennsylvania

How to Use This Playbook 

Our goal is to give global health organizations the tools to create successful and sustainable POCUS programs focusing on maternal health. This playbook is designed to provide a framework for POCUS adoption and implementation for maternal health use-cases in limited-resource settings. Each organization that utilizes POCUS should have at least one credentialed sonographer that’s available to carry out scans.

About Ilara Health 

Ilara Health is a global health organization that makes low-cost diagnostic tools accessible to the 500 million people in Africa who today struggle to access even a simple blood test. Since 2019, they’ve leveraged Butterfly devices to help bring medical imaging to thousands of patients at dozens of clinics across Kenya, with a strong focus on obstetric assessment.

This guide was created by leveraging their experience and expertise. 

Step 1: Selecting the right care facilities

Making the most of your credentialed¹ sonographer(s) and clinicians can often come down to the selection of the best possible care facilities, where POCUS will be able to have the greatest benefit. Ilara achieved this through the use of a rigorous facility questionnaire, sent out to and completed by all facilities that were candidates for participation in the organization’s Butterfly operation. This questionnaire included questions like the following:

• How many patients do you see on a typical day?
• How much does your average patient pay?
• What maternal health services do you currently offer?
• What other hospitals or health centers serve the patients in your area?
• At this moment, when patients come to you needing ultrasound, how do you respond?

These questions allowed Ilara to determine two things. First: is there an urgent need for POCUS at this facility? And second: is this facility likely to repay monthly fees to allow a POCUS operation to be sustainable and, therefore, as beneficial as possible?

Step 2: Training local clinicians

Depending on how familiar your clinicians are with POCUS, training them to confidently and competently carry out scans may be one of the more time-intensive steps in the creation of your POCUS initiative.

To begin the training process, ensure that your credentialed sonographer(s) are comfortable using the Butterfly device. A short product demo (lasting around 15-30 minutes) is typically sufficient to get sonographers familiar enough with the interface to perform their usual ultrasound functions with the device. 

Onboarding the nurses, midwives and other clinical officers who will carry out the bulk of in-person scanning and probe use requires a more rigorous process. Ilara broke this training process into two components: remote ultrasound basics, and live onsite Butterfly instruction.

Ultrasound basics training

The first half of this training regimen can be completed remotely. Though each group of clinicians will learn at their own pace (and therefore demand customized learning schedules), Ilara found that 5 or 6 short online sessions were typically sufficient for clinicians to attain a basic understanding of ultrasound’s technical operation.

The training goals were:

• To equip clinicians with basic anatomical knowledge required for ultrasound scanning.
• To equip clinicians with basic technical knowledge on how to operate an ultrasound machine (this includes virtual demonstrations with the Butterfly app).
• To train clinicians on probe handling and movements used in ultrasound scanning.
• To ensure that clinicians are working in accordance with the American Institute of Ultrasound in Medicine’s ALARA (As Low As Reasonably Achievable) principle.

Before moving on from this portion of the training, test your clinicians to ensure they have a strong foundation of ultrasound comfort to build upon.

Hands-on Butterfly training:

the second half of the training regimen should focus on establishing clinician confidence and competence using a Butterfly device to carry out standard obstetric scans. The goals of such care will include the monitoring of pregnancy from 5 weeks of gestation to term, as well as identifying which expectant mothers are at a higher risk of rupture and other complications. This training should take place during in-person, infield sessions where clinicians perform scans on real patients under the supervision of an assigned sonographer, or already-trained clinical officer.
These sessions require accommodation of your facilities’ schedules, and their ability to provide expectant mothers who are willing to be scanned.
As a whole, initial training should focus not on total mastery, but on basic confidence and competence performing all the components of an obstetric scan, including:

• Determining the number of gestations
• Determining the orientation of the fetus
• Dating a pregnancy by measuring the biometric parameters
• Locating a placenta
• Assessing amniotic fluid levels
• Measuring fetal heart rate
• Measuring cervical length
• Identifying any fetal anomalies

This training should also ensure that clinical officers are comfortable performing these tasks as part of a TeleGuidance™ operation, with your sonographer calling in remotely. (This will later become crucial to your ability to scan as efficiently as possible.)

Finally, once you’ve trained a group of clinical officers to confidently use the Butterfly devices to perform obstetric exams, consider employing a cascading training scheme to help disseminate the learnings as widely as possible among your staff.

A cascading training scheme is one in which each trained user relays the training along to additional users. This makes training more efficient, and will help build a sense of excitement and trust around POCUS within your team. It’s most helpful if some of the POCUS enthusiasts passing along their knowledge to other clinicians are local to the clinic or care site. 

Step 3: Delivering POCUS care

“As a sonographer, my core responsibility is to give accurate imaging diagnoses in the shortest time possible to improve clinical decision-making. It's my joy to be able to help facilities conduct scans regardless of the location, especially the facilities where there are typically few or no sonographers.”

-Kendi Pierah, Sonographer, Ilara Health

With training completed, it’s time to unlock the power of POCUS to bring medical imaging to even more mothers in the areas you serve. Utilize TeleGuidance to complete obstetric scans across care sites with your sonographer(s) remotely guiding your trained clinical officers. 

Aim for efficiency

As you roll out your POCUS program, keep big-picture goals in mind. One big-picture goal of a maternal-health POCUS program is to more efficiently utilize your sonographer(s). Because so many of the patients in low-resource settings lack access to the facilities where sonographers work, the sonographers at the facilities Ilara serves had traditionally been highly underutilized, often serving only 2-3 patients a day. Once TeleGuidance enabled them to serve patients in facilities across Kenya, these same sonographers were able to dramatically increase this number to 16-20 patients daily. 

Contextualizing scan goals

To get the most out of your increased scanning capacity, it can be helpful to have different scanning goals for different scanning contexts. For patients who have not presented with bleeding or other abnormalities, Ilara recommends performing two obstetric scans before delivery. These scans should focus on determining whether any of these patients are at greater risk of hemorrhage or other complications, by looking for:

• Multiple gestations
• Abnormal placentation
• Abnormally large fetal measurements
• Excessive fluids

Whenever a patient presents with symptoms like bleeding, abdominal pain or abdominal distention, an emergency scan can help determine the cause (ectopic pregnancy, extra-uterine pregnancy, or miscarriage), and guide management of the abnormality. 

Step 4: Finding a sustainable economic model

Your organization’s goal is to provide the best care possible for as many patients as possible. Achieving that goal can sometimes require charging for scans in order to create a self-sustaining POCUS operation.

There is no one-size-fits-all economic model for any care practice operating in a limited-resource setting; economic flexibility can in fact be crucial for survival. Ilara experimented with multiple traditional pricing models, including: 

• Providing clinics with full care packages (a Butterfly device and a sonographer), and charging a flat fee per day.
• Revenue-splitting with clinics, both with and without a minimum fee.
  

Experimenting with different options can reveal, in time, what works best for your operation. Working alongside your facilities to calibrate a pricing model can be helpful for both parties. 

“A dedicated sonographer can be hard to find, and is often an expensive resource in these settings. Using this kind of a program helps facilities offer the service in a pragmatic and sustainable way, and ultimately helps patients access it.” 

-Samantha Ponte, Program Manager, Ilara Health

Step 5: Measuring success, evaluating impact

The particular markers you use to measure the success of your program will of course vary depending on your care context. For Ilara, the most important indicator of success was the number of facilities they enabled to perform regular obstetric scans. 

Some other questions you might ask to evaluate the impact of your operation: 

• Approximately how many scans in total were performed? (This can be estimated using Butterfly Cloud.)
• Approximately how many scans were performed that identified complications and critical emergencies? 
• Approximately how many scans were performed that led to changes in case management or treatment?
• Approximately how much did the implementation of remote sonography reduce the average wait time of a typical patient? (Ilara estimated this indicator by creating a controlled experiment that compared average wait times with and without use of TeleGuidance.)
• Approximately how much did the implementation of Butterfly reduce the price of a typical scan at each facility?
  

Overcoming Challenges

Though every care context can be vastly different, it’s useful to try to anticipate possible obstacles that might block your organization from implementing POCUS. 

Here are a few of the obstacles you may face: 

1. Price of care. Simply put, the price charged for a scan is most frequently the barrier for patients.  
2. Patient comfort with TeleGuidance. For some patients, receiving care under the guidance of a doctor who’s not in the room can be an unfamiliar experience, and taking time to introduce the technology is key.
3. Probe recharging. During high-volume days, probes may need regular recharges. 
4. Probe Overheating.
   

And how you might address them:

1. If compliant with the laws of the country in which you operate, offer discounts for patients who book scans in advance. This can help simultaneously increase demand, keep prices lower for each individual patient, and allow your facilities to continue to collect the revenue they require.
2. Have clinical officers narrate the care process to their patients. ‘We’re going to do a routine scan...here’s what we’re looking for...this is why we have a doctor on the phone.’ 
3. Encourage a habit among your clinical officers to recharge probes while filing scan reports in between patient visits.
4. The Butterfly probe will automatically shut down before it reaches unsafe temperatures.
   

Remember the value of your work

“We would interview patients, patients who have had children already, and we’d ask them if they’d ever been scanned before. They’d say no—this was the first time they’re seeing their unborn child. It really showed the magnitude of the problem.” 

-Sven Modrow, Head of Special Projects, Ilara Health

Don’t lose sight of the immense value of maternal health in limited-resource care settings. Beyond their invaluable guidance as an exemplary maternal-health partner, Ilara Health provides inspiration and motivation on the importance of expanding ultrasound access to more expectant mothers. The information POCUS brings to the surface can even have implications for entire communities. 

One of Ilara’s sonographers recounted that, at the very first facility where she helped implement TeleGuidance, she observed over the course of her training consistently low fetal weights. This information, which would’ve gone undetected if not for POCUS, inspired her to raise the issue with the directors of the facility—who then reached out to the Kenyan Ministry of Health and the World Food Program to initiate a food program for the mothers within the community. 

Visit our Global Health page for information on joining the Butterfly Global Health program.

Contributors:
‍Sven Modrow, Head of Special Projects, Ilara Health
Samantha Ponte, Program Manager, Ilara Health
Kendi Pierah, Sonographer, Ilara Health
Fred Korir, Project Lead, Ilara Health
Rebecca Muthoni, Sonographer
Emilian Popa, CEO & Founder, Ilara Health
Jill Kalman, Chief Clinical and Scientific Officer, Butterfly Network

¹Though the process for sonographer licensing varies country to country, Ilara’s sonographers are required to have a diploma or degree in medical imaging or radiology from an accredited institution and a license from the Kenya Radiation Protection Board.

For use by qualified and trained healthcare practitioners.

The material presented herein is for informational purposes only. The information is not a substitute for professional clinician training and experience. Clinicians are solely responsible for patient care and for exercising their independent clinical judgment at all times. Always comply with local and regional regulations surrounding ultrasound.

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