For two years, ambitious initiatives in sub-Saharan Africa have demonstrated how pocket-sized ultrasound technology can help bridge the gaps in maternal care access. The implementation of Point-of-Care Ultrasound (POCUS) across hundreds of healthcare facilities provides new insights into how innovative deployments of technology can combine with comprehensive training to transform maternal health outcomes in resource-limited settings. The initiative has trained over 1,000 healthcare workers and has led to pregnancy scans and counts of over 1 million people.
The World Health Organization (WHO) recommends ultrasound scans 24 weeks in advance for all pregnancies, but the harsh reality of access to high-quality, global maternal healthcare presents immeasurable challenges. Almost 95% of maternal deaths occur in low- and middle-income countries (LMICs). Additionally, in low-resource settings such as sub-Saharan Africa and parts of Asia, the high cost of equipment and the need for trained sonographers means that few women can access ultrasound. UNICEF's 2021 report on child mortality and WHO's 2024 report on maternal mortality shows that in sub-Saharan Africa alone, around 202,000 mothers and 27 infants die annually from childbirth complications. Several factors contribute to these statistics, but one important barrier is limited access to prenatal diagnostic imaging. This is an important tool for identifying life-threatening complications during pregnancy.
Many parts of the world, especially LMICs, are essentially diagnostic deserts. The lack of fair and accessible primary health care for women, coupled with the higher disease burden that enters pregnancy, creates a complete storm of risk factors demanding innovative solutions.
Opening new ground in Kenya
The project began in Kenya in late 2022, with 500 single-probe full-body portable ultrasound devices deployed at 224 healthcare facilities in Kenya. This, combined with ultrasound training by the Global Ultrasound Institute (GUSI), provided over 500 frontline healthcare workers with care in Kenya counties, providing disproportionately high rates of maternal and neonatal mortality and morbidity. Participant recruitment and implementation assessments were conducted by Kenyatta University.
Initial results from the assessment conducted by Kenyatta University suggest that 90% of healthcare workers reported identifying high-risk conditions such as pre-placenta syndrome and using the device within one month of training.
Findings from the study represent the largest impact study on point-of-care ultrasound so far in Africa, indicating:
95% of participant providers currently use PoCus to detect high-risk conditions and inform treatment decisions. 80% of participant providers train at least two other providers in hospitals to further promote wide-scale use. In a survey of over 2,000 medical users or pregnant women, 48-55% reported having a pocus scan during their visit (more than twice as many as previous pregnancy).
The training program, developed in collaboration with GUSI, takes a comprehensive approach. It starts with creating the foundation of local expertise by training sonography with more than 50 Kenyan clinicians in Obstetrician and Gynecology (ISUOG) Standard Technology to become trainers. The curriculum covers manipulation, image acquisition and medical decision-making, with a particular focus on identifying high-risk conditions during pregnancy.
Phase 2 of the Kenya programme included the GUSI curriculum. This required pre-tests and participants to record at least 20 of at least five scans during the week. Post-test and final objective structural clinical testing (OSCE) were conducted on the last day of the program. Participants who passed all training and tests were given a certificate at the closing ceremony.
As of December 2024, the Phase 2 study results were significant. For the 24 months since training began, clinicians in Kenya have performed over 496,000 scans, with over 95% of their equipment continuing to serve as an important part of midwives' care workflows at these facilities. These data demonstrate the sustainability of Pocus when the approach combines intensive training for midwives with easy-to-use equipment.
Expansion of impact: South Africa's implementation
Based on its success in Kenya, the programme expanded to South Africa. There, maternal mortality and mortality rates remain disproportionately high, especially in rural areas. The initiative was deployed in multiple provinces that began in April 2024 in the Eastern Cape. At this stage of training, learners received additional guidance on fetal biometrics. This provided rich details about fetal health and growth, as well as checking the estimated date of pregnancy, as well as ultrasound examinations that provided details about fetal health and growth. The implementation and evaluation of this phase was led by the Clinton Health Access Initiative and the University of Pretoria.
The official evaluation results will be released soon, but the preliminary results are extremely promising. South African learners performed over 573,000 scans and completed over 41,000 instances of fetal biometrics. To sum up, these scans represent thousands of opportunities for mothers to be educated about their pregnancy status and make an informed decision about additional testing or referrals if complications are suspected.
Medical users need to facilitate access to prenatal imaging, and clinicians need the better ability to screen for high-risk conditions where pregnancy outcomes are disproportionately worsened, especially in rural areas. The more accessible ultrasound, more risky conditions are identified early and results are improved.
Technique and training formula
What sets this initiative apart is its comprehensive approach to implementation. The program provides valuable insight into how to effectively scale the deployment of medical technology in a resource-limited setting. But rather than simply distributing services, the program highlights sustainable integration into existing healthcare systems. This includes:
Intensive Training Program for Healthcare Professionals Continuous Remote Quality Assurance Review and Mentoring Trained Health Providers for Partnerships with Local Academic Institutions, Integrating Impact Assessment with Existing Maternal Health Protocols and Collaboration for Local Health Policy Development for Collaboration with Local Distribution and Support Networks
Looking for the future: Impact on global health
Collaboration between multiple stakeholders, including the Clinton Health Access Initiative, GUSI, Kenyatta University, and local healthcare institutions, provides a model for the implementation of future health technology. It shows how public-private partnerships can work together to address complex healthcare challenges while ensuring sustainability and local ownership.
As the program continues to expand (Kenya, Chai, South Africa, and Nursing School at Kenyatta University, University of Pretoria), researchers are assessing the impact on broader health system metrics, including referral patterns and population-level maternal health outcomes. This data is needed to understand how to most effectively deploy PoCus technology to improve maternal health outcomes in similar environments around the world.
This initiative goes beyond technology. This represents a comprehensive approach to addressing maternal health disparities through innovation, education and systematic support. We must advocate for better maternal and primary care for all, especially for mothers who live in resource-restricted environments during pregnancy. It also needs to address racial and socioeconomic disparities in health access and improve the quality of healthcare across the continuum. Ultrasound also plays a role at every stage. Providing affordable point-of-care diagnostic tools helps to quickly and efficiently assess the well-being of all people, especially pregnant mothers. This will allow healthcare providers to become better diagnosticians and improve overall patient care, especially for those at risk.
As global health leaders continue to seek solutions to reduce maternal mortality, the program offers valuable lessons on how to effectively bridge gaps in healthcare access in resource-limited settings.
The above initiative was supported by a $5 million grant to the Butterfly Network.
Photo: Lid Franz, Getty Images
Sachita Shah, MD, is Vice President of Global Health at Butterfly Network, Professor of Emergency Medicine, and Professor of Global Health at the University of Washington School of Medicine. She is the director of ultrasound education for a global nonprofit organization called Partners in Health, who is past chair of the International Ultrasound Subcommittee of the University of Emergency Physicians and past chair of the Global Health Community of the Institute of Ultrasound Research in American Medicine. She balances the time between academic emergency care in the United States and care point ultrasound examinations for PIH in low-income countries. Her academic research and clinical services focus on the impact of point-of-care ultrasound in limited resource settings, and note how training and training strengthens health systems and affects maternal and emergency patients outcomes.
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