Gaping inequity in rural antenatal ultrasound access

Researchers have called for more investment in portable ultrasound machines and upskilling to address stark antenatal care inequalities in rural areas. 
 
The perinatal death rate in very remote areas is more than twice the metropolitan level, and a University of South Australia (UniSA) study suggests that improved access to antenatal ultrasound is key to reducing that gap.
 
Analysing the results of a survey of 114 medical professionals from around the country, the authors of the UniSA study called for ‘a coordinated approach’. They cite Australian Institute of Health and Welfare (AIHW) statistics that show a rate of 19.6 deaths per 1000 births in very remote areas compared to a national average of 9.6 per 1000.
 
‘The most significant obstacles to the provision of antenatal ultrasound services identified in this survey were: lack of trained staff [including access to training opportunities] and inaccessibility of ultrasound equipment,’ they wrote.
 
Dr Kaylene Girgenti is the Chair of the RACGP’s Doctors for Women in Rural Medicine Committee and recognises the issues discussed in the study. She describes ultrasound access in rural areas as ‘a huge deficit’.
 
‘I’m constantly shocked and amazed about how far people sometimes have to travel to access those services,’ she told newsGP.
 
‘Driving for seven hours for basic routine imaging is just crazy, and it’s no surprise that people sometimes make the choice not to do that.’
 
While the survey suggests the issue may partly be linked to pregnant patients in more remote areas not recognising the value of ultrasound as much their metropolitan counterparts, Dr Girgenti believes the logistics are likely to be the most significant factor.
 
‘Weighing up the time investment, the costs of fuel and travel, the need to arrange childcare and rearrange the whole family life, probably on balance they make the decision and the choice that they can do without it,’ Dr Girgenti said.
 
One of the authors of the study, Amber Bidner, is also a Research Project Manager for the ongoing UniSA Healthy Newborn Project, where she works with colleagues, Associate Professor Nayana Parange and Professor Eva Bezak.
 
Funded by The Hospital Research Foundation, the project aims to give remote doctors and midwives more scope to use antenatal ultrasound and has run training courses for clinicians, including GPs, in Adelaide and in Alice Springs.
 
Ms Bidner, who has previously worked as a registered nurse and nuclear medicine scientist, believes scan costs and Medicare rebates for antenatal imaging need to be reviewed.

She says historically there has been a very uneven approach to ultrasound in remote areas.
 
‘One respondent said, “I’m using my phone with FaceTime while the clinician is at the other end telling me where to hold the probe, and I’ve had no training”,’ she told newsGP.
 
‘There is no legislation around ultrasound in terms of who can and can’t use it, so any clinician could just buy their own ultrasound machine and start scanning – and obviously that’d come with risks of misdiagnosis and all sorts of other problems.’
 
A clear aim for improving access and training is to increase the detection of high-risk pregnancies and fetal abnormalities.
 
‘The ultrasound … picks up these things, which then allows care to be provided so that we’re avoiding the mortality down the road and providing a better plan to care for these women,’ Ms Bidner said.
 
She reports clinicians who have taken part in training are also seeing another important effect.
 
‘They’re finding that the patients are attending their appointments more regularly, that they’re becoming more engaged with the pregnancy, they’re following their care directives more,’ she said.
 
‘Ultrasound is an amazing tool to direct care.’
 
Ms Bidner also highlights the importance of follow-up training.
 
‘We’ve proven that we can upskill clinicians with these intensive training programs, but you can’t just send them back off to the back of Central Australia and “go see you later, guys”,’ she said.
 
‘Ultrasound is a very operator-dependent skill, and they need additional support following that.’
 
According to Ms Bidner, technology is also making that easier.
 
‘We are seeing these incredible systems becoming available where the clinician can be operating the ultrasound probe and the specialist is sitting hundreds of kilometres away in a city centre,’ she said.
 
‘They can not only see the patient and the probe and where it’s positioned, but also the scan itself.
 
‘And they can control some of the functionality of the ultrasound equipment as well.’
 
She would like to see more clinicians evolve from point-of-care ultrasound training to full accreditation through the Australasian Society of Ultrasound and Medicine (ASUM).
 
Ms Bidner also hopes a sustainable, accessible program for all rural Australia can be developed, with the collaboration of ASUM, and potentially other organisations including the RACGP.
 
‘With all the problems we have with attrition of rural clinicians, giving them this skill and support to be able to get a program like this up and running … would really help towards empowering them and keeping them in rural workplaces,’ she said.
 
For Dr Girgenti, such a move would be worthwhile, provided newly developed expertise can be put into action.
 
‘Upskilling GPs and ultrasonography skills would be a valuable investment, as long as the GPs are going to be able to use those skills regularly,’ she said.
 
‘That’s the most important thing.’
 
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antenatal care perinatal care rural medicine ultrasound