“Move the ultrasound scanning machine to where the woman is”: Stakeholder perspectives and experiences of task-sharing antenatal ultrasound scanning with trained midwives in Blantyre, Malawi.

In 2018, Malawi adopted the World Health Organization antenatal care (ANC) recommendation of at least one ultrasound scan (USS) for pregnant women before 24 weeks gestation. A shortage of trained providers and USS machines, however, has significantly hindered implementation. A qualitative study explored diverse stakeholder perspectives on integrating USS into ANC services through task-sharing with trained midwives in 10 primary health centers in Blantyre, Malawi. We conducted seven focus group discussions with 58 stakeholders, including midwives, current ANC clients, policymakers, male partners of pregnant women, women that had given birth in the last 16 weeks, nurse/midwife educators, and community representatives. Discussions were audio-recorded with consent, transcribed and translated. Topics included acceptability and feasibility of task-sharing, experience with point-of-care USS (POCUS) devices and recommendations for scale-up. Data were coded in NVivo and thematically analyzed. Four themes emerged. [1] Community sensitization and male involvement are needed for successful integration of antenatal USS and scale-up of task-sharing with midwives. [2] Stakeholders perceive that antenatal USS has a positive impact on continuity and quality of care, specifically early detection of complications, womens birth preparedness, and referral-related cost- and time-savings. [3] Main barriers to USS implementation were unmet expectations among clients for USS results counselling, increased midwife workloads and client wait times, midwives perceptions about the challenging nature of the training content, and device-specific challenges. [4] Integrated scale-up requires the inclusion of USS in midwives official scope of practice, more POCUS devices, and standardized training of all midwives in Malawi to provide USS at the primary care level. Stakeholders supported task-sharing of USS to midwives and integration into routine ANC. They provided valuable feedback and specific recommendations for successful scale-up.