Barriers and Enablers That Influence Utilization of Ultrasound Screening Services among Antenatal Women in Kajiado and Kisii Counties Kenya

Background: The World Health Organization recommends to have all pregnant women to undergo an obstetric ultrasound scan before 24 weeks gestation. However, this has been a challenge as a result of limited access to appropriate Point of Care Ultrasound Screening (POCUS) services in lower le-vels of developing countries’ Health Systems, cost of care, skills gap among care providers and unclear regulatory policy frameworks. Obstetric Ultrasound scan helps to confirm viability of a pregnancy, gestational age, multiple pregnancies and it also helps rule out fetal abnormalities early enough. Methods: One year after intervention, a cross-sectional study was carried in the two pilot counties of Kisii (rural) and Kajiado (peri-urban). This followed after selected midwives in the two counties were trained on basic obstetric ultrasound screening for ANC women. A total of 366 women who were either in their last phases of pregnancy or had delivered within three months before the survey were interviewed. Cumulatively, the 36 midwives had screened 1,250 mothers out of whom 18 high risk pregnancies were identified. Open Data Kit (ODK) was used to collect quantitative data and analysed using STATA version 15. Descriptive statistics were used to while 48% had secondary level of education. Only 21% of the women had undergone routine ultrasound screening before 24 weeks of gestation with the average distance travelled by majority (45%) of the respondents to access the POCUS service being 3 - 5 km. The need to confirm a pregnancy’s gestation was the major (68.1%) motivator for seeking the service in the two pilot counties. Employment status, household income, education level, pregnancy gestation and distance to the facility had a statistical significance (P < 0.05) with ultrasound utilization. Highest education level, pregnancy gestation and distance to the nearest ultrasound screening facility were found to significantly predict the likelihood of utilizing the ultrasound services (P < 0.05). The initial training and continuous hands-on coaching of midwives by TOTs contributed a lot to acquisition of the desired basic obstetric ultrasound screening skills. Conclusion: Women in developing countries are eager to access obstetric ultrasound screening services but for limited opportunities and sustainable implementation frameworks on Point of Care Ultrasound Screening (POCUS) services. Training and continuous coaching of frontline health professionals are critical in deployment of POCUS but there is limited access to standardised training content.

ter selected midwives in the two counties were trained on basic obstetric ultrasound screening for ANC women. A total of 366 women who were either in their last phases of pregnancy or had delivered within three months before the survey were interviewed. Cumulatively, the 36 midwives had screened 1,250 mothers out of whom 18 high risk pregnancies were identified. Open Data Kit (ODK) was used to collect quantitative data and analysed using STATA version 15. Descriptive statistics were used to summarize the data test associations between variables. Bivariate and logistic regression was used to identify predictive variables, and ORs with 95% confidence intervals used to measure the strength of the associations. Findings: Slightly more than a third (36%) of the women had recently delivered. In total, Kisii (rural county) had a representation of 59% of the respondents. Half of the respondents were aged between 25 -34 years, 55% of the women interviewed were housewives

Introduction
According to the International Federation of Gynaecology and Obstetrics (FIGO) report [1], obstetric ultrasound is an integral part of prenatal care for pregnant women. Unequal distribution and high cost of obstetric ultrasound technology in low resource settings have continued to affect access and utilisation of early pregnancy obstetric ultrasonography services. Further to this, the World Health Organization (WHO) [2] concurs that, a midwife with a full-scope of midwifery skills, is able to meet 87% of the needs of pregnant women and newborns. However, the developing countries' health system [3] is one with staffing shortages aggravated by limited financial muscle for governments to hire additional staff; in Kenya only 30% of the 3000 plus nurse midwives that graduate annually get formerly secure employment.
Women in Sub-Saharan Africa are yet to embrace early pregnancy ultrasound screening due to factors that vary from individual challenges in health seeking behaviours to health facilities capacity limitations and unclear national policies environment [4]. While WHO recommends at least one Obstetric Ultrasound for pregnant women [5], FIGO recommends two ultrasound screens for all pregnant women during the first and second trimesters to mitigate risks associated with adverse perinatal outcomes.
In Kenya, only 62% of pregnant women have access to skilled care and comparatively, 50% of pregnant women in rural areas receive skilled care compared

Intervention
A pilot project got initiated in two pilot counties in Kenya to assess midwives' uptake of basic obstetric ultrasound screening skills and women's utilisation of

Data Collection
A structured questionnaire converted into a mobile application tool open data kit (ODK) was used to elicit information from mothers who were either in their last phases of pregnancy or had delivered within three months before the survey.
Six research assistants from each county who had the ability to use mobile phone applications, had a training in health or social sciences and were familiar with the respective regions had a two-day training for this study. The questionnaire and consent forms were pre-tested with 41 (10%) respondents and revised based on feedback received.

Questionnaire
The questionnaire data already captured in ODK was later converted to excel.
The data was later converted to STATA version 15 that was used to calculate descriptive statistics for study variables. Tables were used to graphically show the respective findings. Bivariate and logistic regression was used to identify predictive variables, and ORs with 95% confidence intervals used to measure the strength of the associations. The study adopted a two-sample approach: the difference between two populations (Kisii and Kajiado) with specified anticipated precision being P 1 (0.5) and P 2 (0.5) at a significance level of 0.005.

Ethics
Authorization for data collection was obtained from the relevant administrative authorities in Kajiado and Kisii Counties in Kenya. Oral and written informed consent was the foundation for the participation of eligible midwives. The participants were informed that they could withdraw their participation at any time during the research process. To ensure confidentially, all the questionnaires were coded to prevent identification of any individual participant.

Limitations and Delimitations
The project took place in the period of the COVID-19 pandemic which also li-

Social-Demographic Characteristics of the Respondents
As shown in Table 1 total of 366 women were interviewed from the two pilot counties (representing 88.8%) of the targeted sample size of 412 women. More than half (59%) of the respondents were from Kisii (rural) county while the rest were from Kajiado (peri-urban) county in Kenya. More than a third (36%) of the women interviewed in the pilot sites had recently delivered. Half of the respondents were aged between 25 -34 years while 5.2% were aged below 18 years.
Notably, 68% of the respondents had history of receiving skilled ANC services either recently or in the previous pregnancy. More than half of the respondents (55%) were housewives, 34% were self-employed and 12% were employed. Less than half of the respondents had secondary level of education while 26% had primary level of education and 18% had mid-level college level of education as summarized in Table 1.

Utilization of Ultrasound Screening Services by Women in Primary Health Care Settings
Almost half (49.7%) of the respondents had undergone obstetric ultrasound screening in their latest (current) pregnancy and only 22% (81) had gone for routine obstetric ultrasound screening in their previous pregnancies. Out of the screened respondents, 36% were screened at a gestational age of 25 -30 weeks.
On access to ultrasound screening services, majority of the respondents (45%) travelled a distance of 3 -5 km to access ultrasound screening within the two pilot counties, 17% travelled 6 -10 km and 5% of them travelled for more than 10km to access ultrasound screening services as shown in Table 2. Out of those done an obstetric ultrasound in their recent pregnancy, 71% of them accessed the service in a public health facility within pilot sites, 24% of them got the service in private health facilities and 5% in faith based (mission) hospitals.
As depicted in Table 3 Other factors included financial cost, the type of facility offering the services, distance to the facility, and sex of the health provider offering the service, previous ultrasound experience and the side effects associated with ultrasound as shown in Table 4.

Barriers to Accessing Ultrasound Screening
Overall, Lack of money was identified by the respondents as the main barrier to accessing ultrasound screening. In Kajiado County, lack of ultrasound services, limited awareness, fear of ultrasound side-effects and cultural beliefs were the most critical barriers overall as shown in Figure 1.
Housewives were more likely (50.5%) to undergo obstetric ultrasound screening with the employed women being the least (17.6%) group to do the same.
On the average household income, according to the study, the more one earned, the more the likelihood of accessing ultrasound screening. For instance, out 22 respondents who earned $ between $ 301 -$ 500, 81.8% of them were able to access ultrasound while all the respondents who earned ≥$ 700 were able to access the service. On education level, out of 13 respondents who had attained university education, only one (7.7%) did not access ultrasound services com-

Predictors of Ultrasound Utilization
As summarised in  In relation to the pregnancy gestation, the odds of utilizing ultrasound services was found to be 4.201 times greater for participants in their second trimester as opposed to those in their first trimester. Similarly, the odds of utilizing ultrasound services was 6.187 times greater for participants in their third trimester as opposed to those in their first trimester.
Distance to the nearest ultrasound screening facility also had a significant effect in predicting the likelihood of utilizing the ultrasound services. For instance, the odds of utilizing ultrasound services was much lower for participants whose nearest ultrasound screening facility was more than 10 kilometres from where they lived as compared to those whose nearest ultrasound screening facility was less than 3 kilometres away.

Discussion
Ultrasound has become an indispensable part of modern antenatal care (ANC) in both developing and industrialized countries. Ultrasound is safe, portable, less expensive than other imaging modalities, non-invasive, and has a real-time imaging capability that is essential in obstetrics. The recent advances in methods of prenatal diagnosis, particularly prenatal ultrasound have resulted in a better understanding of certain congenital anomalies and consequently, the improvement in surgical and medical procedures to treat birth defects earlier with improved outcomes [12].
It is generally accepted that in majority of developing countries and mostly in rural areas, diagnostic imaging is often insufficient, and in some instances completely lacking. However, over the past decade, the use of clinician-performed, hand-carried, bedside ultrasound has gained increasing popularity as a useful imaging modality worldwide, helping to boost the diagnostic capacity in rural areas in resource-limited settings. Although utilization of ultrasound technology differs across countries, emerging increase in ultrasound services utilisation is Open Journal of Clinical Diagnostics likely to be due to several factors, including the increased affordability, availability, portability and durability of ultrasound machines [13].
In majority of low middle income countries, ultrasound is mainly used to diagnose obstetric conditions [14]. Unlike in a study in Liberia where 53% of women utilised related obstetric ultrasound screening service [15], this study recorded approximately half of the respondents had utilised obstetric ultrasound screening services in the selected pilot sites. It is however higher compared to a trial conducted in a refugee camp in Tanzania where only 24% of the exams were obstetric while 21.9% were gynaecological [16]. If the above figures are anything to go by, it shows that ultrasound utilization remains low in developing countries. Training of midwives on how to perform basic obstetric ultrasound screening is very critical and valuable enabler; though based in the Nairobi metropolis, findings from a related study at the Agakhan University Hospital [17] established a higher competency rating with an accuracy of 99.63% among the midwives who had been trained using standardised content. However, in the Agakhan study, images were instantly shared with radiographers via internet to ascertain diagnosis.
A number of barriers to ultrasound services have been documented. In a study carried out in five low and middle income countries, 71% of patients referred made no attempt to be screened due to high costs involved while 16% could not afford bus fare to the referral health facilities that had ultrasound machines [18].
Similar to this study, the cost of ultrasound services and distance or transportation difficulties were observed to be common barriers when it comes to utilization of ultrasound services. In our study, the likelihood of utilizing ultrasound services was higher among mothers living near the facility unlike those living far away from health facilities that have POCUS services.
In a qualitative study carried out in Tanzania, all the health workers were in agreement that ultrasound remains a highly valuable tool in management of complicated pregnancy though diverse views were brought up whether routine screening ultrasound should be offered to all pregnant women. According to one of the respondent, every woman should have two screening ultrasound examinations, one in the second trimester to determine gestational age and detect fetal anomalies, and another in the third trimester to prepare for any deviations at birth [19]. Similar to the Tanzania study, most of the women who turned for ultrasound screening in this Kenyan study were in their second trimester. Probably this is due to limited awareness among women why they should start ANC visits within the first trimester or as soon as they realise they are pregnant. Unlike in our study where a statistical significance was recorded between utilization and occupation of the respondents, none was found in a study done in Nigeria to determine the factors affecting utilization of obstetric ultrasound services by pregnant women [20].
In a study to determine the maternal perception of barriers to utilization of perinatal ultrasound in the northern part of Nigeria, some of the key factors according to the respondents included necessity of the scan, distance to service point, financial cost, waiting time and satisfaction with service [21]. The findings are similar to our study in which customer care, level of privacy, benefits of ultrasound screening and waiting time were identified as the key influencers to utilization of ultrasound services. In another study carried out among pregnant mothers on how prenatal sonographic services can be improved, good communication between the patient and the sonographer, reducing the cost of scan, reducing the patients' waiting and creating more awareness were some of the opinions shared. In summary, enablers and barriers to utilization of prenatal ultrasound as prenatal care tool are intimately related to, cost, service satisfaction and knowledge of mothers among other factors.

Conclusion
Prenatal ultrasound covers all aspects of ultrasound imaging tests performed during pregnancy for a variety of reasons. It remains one of the most important advances in antenatal care worldwide given its documented benefits. Key barriers to utilization of this important service include distance to the facilities, inadequate knowledge on the benefits of ultrasound services and the rising cost of these services in the health facilities. From this project, there is evidence that obstetric ultrasound can be cost-effectively decentralized to PHC settings to improve on the quality of antenatal care.

Recommendations
• Stakeholders need to improve women's knowledge on the benefits of ultrasound screening to improve utilization of obstetric scan. • National and county governments need to have sustainable financing mechanisms for women to access routine ANC ultrasound services as recommended by WHO.
• Now that ultrasound screening technology is portable, there should be me-chanisms instituted by local and national governments to train frontline health care professionals on the same.
• Developing countries to develop clear policy frameworks on how task sharing in the area of obstetric ultrasound screening can be carried out to bridge the gaps of women accessing obstetric ultrasound screening services in developing countries.
• To rapidly accelerate accessibility to the service, Low and Middle Income Countries (LMICs) should have standardized training resources in obstetric ultrasound screening training for frontline health professionals.