Nurse-led point-of-care ultrasonography with telemedicine review to improve the impact of antenatal care: a formative qualitative study in Kenya

The informal settlements of Nairobi have higher neonatal and infant mortality rates than the average for Nairobi. Universal access to important diagnostics like ultrasonography is poor and inequitable due to the high cost of devices and limited availability of skilled sonographers. Recent advances of mobile ultrasound probes connected to smartphones, with or without artificial intelligence support, have improved access to devices; but skills to perform and interpret scans continue to be limited. The SonoMobile intervention involved training nurse-midwives to conduct point-of-care obstetric ultrasound scans in antenatal care clinics in urban informal settlements. Scan data and images were shared, using telemedicine technology, with remote sonographers, who reviewed scan images and data, and provided reports. This qualitative study of 61 respondents from diverse stakeholder groups describes the acceptability, utility and potential sustainability of nurse-led, point-of-care obstetric ultrasonography with telemedicine review. Perceived value of nurse-led obstetric ultrasonography include improving access and affordability of obstetric ultrasonography services, timely identification and referral of high-risk pregnancies, and improving awareness of appropriate antenatal care among underserved populations. The relative affordability of SonoMobile was described as a critical enabler for a business model targeting low- and middle-income segments of the population, and for increasing quality and equity of antenatal care coverage. Areas highlighted for improvement include strengthening supervision of nurse trainees, broadening the scope of nurse training, and development of clear regulatory guidelines for nurse-led obstetric ultrasonography. The study highlights the complex task shifting required to provide universal access to a life-saving technology in an LMIC health system. ### Competing Interest Statement MBK and PK are directors in Health-E-Net Limited, a digital health social enterprise based in Kenya involved in delivery of point-of-care ultrasound scans using a commercial model. No other authors have any declared conflicts of interest. ### Funding Statement This study was funded by the Italian Agency for Development Cooperation. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics Review Committee of Strathmore University gave ethical approval for this work (#SU-IERC0795/20). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors