the UVM Medical Center radiologist Kristen DeStigter, M.D. is co-founder of Imaging the World (ITW), an organization which has developed a medical outreach model designed to provide low-cost ultrasound machines to the most under-resourced areas in the world. Last summer, Dr. DeStigter blogged about the work her organization was doing and their plans for the future. Recently, the UVM Medical Center reporter Kim O’Leary sat down with Dr. DeStigter to learn what Imaging the World has been up to over the past year. This blog is the first in a three part series.
You just returned from a trip to Uganda to evaluate how your OB ultrasound implementation has been going in its first full year. Why have you chosen to focus in this clinical area and what kind of results are you seeing?
A lot of women die in the rural villages from complications of childbirth that are entirely preventable and can be identified with basic ultrasound. In the late 1990s, the World Health Organization (WHO) developed Millennium Development Goals with the idea that by 2015 maternal mortality could be reduced on a global scale, mainly b increasing antenatal care visits during each pregnancy and by making sure more women are delivering at health centers with skilled practitioners. There has been little progress toward this goal in sub-Saharan Africa to date, and most countries will not reach the targets by 2015.
However, ITW is showing incredible results. What we’ve been able to show is that there’s a “magnet effect” for ultrasound when you offer it to women it at the clinic. In a year’s time we’ve shown a 70% increase in the number of deliveries at the health center, and an almost 60% increase in pregnant women coming in for their antenatal visits. Of those visits, the most important two visits are the first and fourth visit. The first visit is to make sure the pregnancy is in the uterus, and the fourth visit is to identify potential complications of childbirth such as the presence of multiples, breech positioning, placenta previa and so on. We’re up 300% in terms of women coming in for their fourth visit alone.
So, we can already see the impact at the health center level by having ultrasound there. We’re also measuring maternal mortality outcomes, but it takes years to get those measurements. It’s been very uplifting for me to see results. It’s something I suspected would happen, but it far exceeded my expectations.
Has anything else surprised you in this first year?
There’s another really cool thing I see happening that goes hand in hand with these results. Uganda has a very male-dominated society. Men traditionally have been very removed from women’s health, especially related to antenatal care, even though they make the health care decisions for the family. We decided early in project that we didn’t have financial resources to give women a printed “picture” to take home with them when they came in for their ultrasounds – even though it was strongly recommended that we do this by the Ministry of Health in Uganda, because it’s important for the women to have documentation of where they’ve been, again, because it’s such a male-dominated society.
An unexpected result of this is that the men are attending the antenatal visits with their wives – the men are even coming into the ultrasound rooms during antenatal appointments (they refer to the ultrasound machine as a “TV”). The nurse midwife is now able to explain to the husband, “This is what we’re doing. The ultrasound is not burning the baby, it’s not making your wife infertile, but look what it’s showing us. We’re seeing if there’s a problem, so you can know that that when she’s in labor, she needs to be at the hospital two hours away.”
So, the men are becoming much more involved. This is defying tradition. Men never showed up at the health centers before. It’s a phenomenon that everyone in Uganda is talking about. The fact that we’re able to drive increases in antenatal visits and deliveries is probably related to the fact that the men are now involved. Now they are saying to their wives “You’re coming back here, you’re going to deliver here,” instead of before, where the women were pretty much on their own to find the means to make it to the health center to deliver their babies.
In your last blog, you discussed the sustainability mission of Imaging the World – “teaching to fish” – with a goal of training professionals to not only perform but also interpret the ultrasounds, so that this model could be adopted in additional locations. How is that going?
The way we implement the Imaging the World model is a phased approach. The first phase involves training the nurse-midwives to generate images to be sent to the internet for interpretation by experts (the nurse midwives receive the results in a cell phone text message). A key point to understand is that, for sustainability purposes, even though the images are sent and viewed on the internet, most of the images are interpreted locally by experts in Uganda. In phase two, we work with other already existing training models, including other organizations like the International Society of Ultrasound in Obstetrics and Gynecology and universities across the country, to train the nurse-midwives to do some very basic interpretations to look for life threatening findings like breech presentation. When they find something they think is abnormal, they need to go to the next step, which is to have the image interpreted by an ultrasound expert.
The reason to have phase one first is that we establish a process for backup, so if there’s a problem and they don’t know what they’re looking at, they have this model already where they’re sending the images to the internet. It also gives us a model for quality assurance. For every tenth case the nurse-midwife interprets, someone in the Imaging the World system can over-read that and make sure we have quality and safety that’s necessary for best practice.
In phase three, a small percentage of these nurse-midwives will decide to become full sonographers and will go for advanced training. Then they will become the trainers in the “train the trainer” system, Since they have been through all of the phases, they can go to the village next door and start the ITW model there.
We’ve just started phase two at this point. Phase one went exactly as expected, and we’re implementing seven new sites in phase one in March 2012 in Uganda.
Check back for the next blog in the series, where we learn how a multidisciplinary team from the UVM Medical Center is working to develop a breast cancer program for Uganda using the Imaging the World breast diagnostic ultrasound protocol.