Approaches, barriers, and facilitators to and strategies for normalizing the provision of ultrasound scanning by midwives in the antenatal clinic

The World Health Organization (WHO) recommends that a pregnant woman get an ultrasound scan (USS) as part of routine antenatal care. The Scale-up and normalization of ultrasound scanning still lag in low- and middle-income countries (LMIC), including Malawi. This study assessed barriers, facilitators, and strategies for scaling up and enhancing the normalization of ultrasound scanning during pregnancy in Malawi.MethodWe conducted one qualitative participatory workshop in each of Malawi’s administrative regional cities, including one workshop in the southern region on 17–18 May 2022, one in the Central region on 20–21 May 2022, and one in the Northen region on 23–24 May 2022. Forty USS trained and untrained midwives, one maternal and neonatal Zonal manager from the Ministry of Health (MoH), two District Nursing Officers (DNO), three district safe motherhood coordinators, and two Tutors from Nursing and Midwifery training institutions participated in the workshops to explore barriers, facilitators, and strategies and develop a training manual for scaling up ultrasound scanning in routine antenatal care (ANC) in Malawi. In addition, a validation workshop was conducted centrally in the central region, on September 22–23, 2022, with four representatives from the Ministry of Health, one from regulatory bodies, three from training institutions, one sonographer, and 10 district and Principal Nursing Officers (PNO) and midwives to validate the manual, which was developed with input from workshop participants. Data was audio recorded throughout the discussion, coded, and thematically analysed using NVivo 12 software.ResultsThe barriers to normalization of USS in routine care include limited capacity and resources, such as a lack of USS-trained staff, infrastructure, including electricity interruptions, and misconceptions. The facilitators to normalization include political will to offer USS, availability of resources including trained midwives, restructuring of service provision, task sharing, revisions of staff allocations, and service integration. The strategies include preservice and on-the-job training, support and supervision, increased availability of resources, improved facility infrastructure, and community sensitization.ConclusionScaling up of ultrasound is possible in Malawi. Staff training, community sensitization, and adequate human and material resources, including a standardised training manual, should be considered when planning USS scale-up and normalization into routine ANC.