Very large country (8 th ) 6.5 M/y in 2011 36 States > 50% rural > 70% poor Gov’t health...
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Transcript of Very large country (8 th ) 6.5 M/y in 2011 36 States > 50% rural > 70% poor Gov’t health...
Nigerian context
Very high maternal mortality rate
5.8% CS rate53% Skilled birth attendant66% ANC (58% regular)
FA significance - Nigeria
Birth Trauma
GE LBW DM Congenital anomalies
Road traffic accidents
CAD CA
24
101.5
23.6
55.4
7.5
21.5
121.6
93.4
Causes of deaths (all ages)
Death rate /100.000
FA - Significance of PND
More important: folate, iodine intake, rubella vaccination, reducing consanguinity, effective family planning
Fetal Medicine - Nigeria
Not only mortality Long term morbidity
Not only fetal anomalies! Twins FGR Fetal disease (anaemia, infection)…
South Africa 1990
No obstetric US service outside the metro
Haphazard routine US service in metro Limited to academic centres Provided by medical practitioners Little connection to obstetric priorities
The scene at the time
Immediate effect - STOP routine scanning- Staff reduction
High risk for fetal anomaly: 20 w FA scan (AMA, teratogens, FH,..)
Low risk women: Selective scanning policy(specific indications only)
Concern – are the RCT data applicable to us? Less restrictive “selective” indications Lower risk populations
The challenge
Finding the place of US in the local setting
RCT: 500 Routine, 500 Selective (low risk)› 100% scanned vs 25% scanned› Dating algorithm for uncertain LMP› Management algorithm for suspected
postdates
First RCT – Results (1996)
No reduction in antenatal visits or admissions or further selective scans
Less undiagnosed twins (+ earlier) Less postdates (9 vs 38), Less PD IOL (1 vs
14)
RCT – Results (1996)
No improvement in adverse outcomes› TPRW OR 0.68 (0.26-1.71)› PNM (9 vs 13) OR 0.70 (0.19-2.47)
More LBW (102 vs 68) OR1.61 (1.13-2.30)
Inconvenient for patients (travel) EXPENSIVE!! (₤ 69 pp vs ₤ 54 for all
care)
The next step - Research
Design a cost–efficient service Maximising benefit Cheap:
› Sonography students (Training started 1994)› Portable machine › Basic scan only› In the community› FREE
Cost-analysis (salary, equipment, consumables, transport…)
The next step – Cohort study
1998, two comparable MOUs N=3009 (718 baseline) – 1 scanning day per week
1 MOU: Routine (basic) US (up to 24w)
1 MOU: Selective US (same indications as before)
Cheap (< 2$ per MOU patient)› No reduced AN visits› No reduced PNM, adverse outcomes› Less undiagnosed twins (earlier)
Cohort study - Results
› Less referrals for “fetal evaluation” (15.9% vs 29.6%, p<0.000)
› More “term” deliveries: RR 0.84 (0.77-0.91)
(79.9 vs 72.5%) - same for spt labours- Less suspected PTL (12.0 vs 16.7%)- Less suspected PD (8.1 vs 10.2%)
› Keeps more women in MOU!› Completely funded by sale of pictures
Dating (2013)
10
20
30
40
50
60
70
80
90
100
≤ 3 days
≤ 7 days
≤ 10 days
≤ 14 daysLMP FH Clinical US
0
2
4
6
8
10
12
14
US <20w 20-24w 24-30w >30w
Absolute error
SD
Pret
erm
Post
term LG
A0
5
10
15
20
25 Not scannedScanned
Dating – Outcomes
Scanned < 24w
Not scanned <24w
02468
10121416
SGA
From Research to Service
Expanded to cover all MOUs Formal post for chief sonographer
› Approx. 5000 scans per year (Anatomy)› Authority to refer directly to level III› Education - Feedback to nursing staff
Roaming sonographer in 2 rural regions › Visit frequency dependent on clinic load› Previously un-serviced area› Drastic increase in referrals to level III
Lessons learnt
Routine work is not for subspecialists Service open to abuse! 2012 – Provincial Policy -
Implementation Drive towards cost reduction Adapt to changing scene – Research
Need to adapt
Urban migration – need for rationalisation
Epidemic of obesity(FH dating)
HIV epidemic(Invasive procedures)
< 25 ≥ 30 ≥ 35 ≥ 400
20
40
60
80
% > 3 weeks overestimation according to BMI
29%
15%
67%
50%
Cost reduction
AMA (37+) vs scan-based risk (1: 200) (retrospective 2003-2005, 136 aneuploidies)
› Sensitivity: - T21 44% 93%- All aneuploidies 44% 94%
› Yield (all abnl) 1:43 1:13
Reduce AMA-procedures by 66% Doubled number of prenatal diagnoses No increase in invasive testing
…Creating the basis
Widespread (but contained) access to high quality screening› Within the community› Cheap
Maximise on general obstetric benefits Fetal Medicine as a bonus
Fetal Medicine 2013
Total obstetric US 8722 Level III 5302
› Fetal anomaly visits 1982› Severe FGR 949› Iso-immunization 138› Complicated twins 711› Genetic screening HR 1460
Diagnostic procedures 325 (1/10+)
1. Theory
Standard text books (some free, online)› www.openultrasound.com› www.fetalmedicine.com
Journal clubs Targeted literature search
› PubMed› UpToDate› OMIM› Cochrane library..
2. Practical Training
You must put in the hours! Practice guidelines Stepwise targets
› Basic› Fetal anatomy survey T2› Soft markers T2› Doppler› Cervix› T1 survey› T1 NT + other markers
2. Practical Training
Keep images for review Assessment and Structured feedback
› ? Telemedicine› ? Simulation models› Online accreditation
e.g. FMF: quality review and ongoing certification
3. Exposure to Pathology
Screening service to create the need Support from laboratory services Academic input from other disciplines
(genetics, cardio, neuro,..) – local context
Need for ongoing audit and feedback› Genetics, Autopsy, Follow up
3. Exposure to Pathology
Visit to international centres› Observer› Fellowship› Formal subspecialty training
Personal Career development
in Fetal Medicine
Development of RELEVANT Fetal Medicine services
Need for ongoing research on priorities in local setting