Interpretation
The study demonstrated that a third-trimester ultrasound at a dedicated scanning clinic could triage patients who needed increased fetal surveillance.
We detected approximately 28% fetuses with FGR, which is less than the meta-analysis, suggesting that when using EFW, third-trimester US had a detection rate of about 35%21 for identifying SGA infants. Our study agrees with Madden et al22 that  SGA infants from low-risk, term pregnancies are at increased risk of serious neonatal morbidity.
Lindqvist et al have suggested that unidentified SGA is a common finding in perinatal deaths 23 This may have accounted for the deaths that were seen in the AGA group given the high prevalence of small babies in the study group(48.59%).
We feel that unlike the Pregnancy Outcome Prediction8study which suggested that universal screening in the third trimester would roughly triple the detection rate of FGR to approximately 57%.,in our setting without a higher threshold for labelling SGA 24or the ability to assess a decrease in growth velocity, this detection rate 25is unachievable.
The Cochrane meta-analysis, 26 IRIS study27and First Cluster Study 28do not support a routine third-trimester scan, suggesting that it does not improve fetal and neonatal adverse outcomes.
The Cochrane meta-analysis found no difference in antenatal, obstetric and neonatal outcomes in ultrasound screened versus control groups. There was no association between ultrasound in late pregnancy and perinatal mortality (risk ratio (RR) 1.01, 95% confidence interval (0.67 to 1.54).
The IRIS trial compared the use of routine third-trimester biometry to clinically indicated ultrasound in low-risk pregnant women. They found no significant improvement between the two groups; however, they used a multidisciplinary protocol for the detection and management of fetal growth restriction, in both the screening strategies.
The above studies are Western trials with excellent antenatal services, a robust midwifery structure, and protocolized management once a small fetus is identified.
In our setting women often receive intermittent and infrequent obstetric care, and the fundal height/palpation may not be checked consistently in the antenatal clinics. In this scenario, many small fetuses may be missed. These could. Unfortunately, even when FGR was identified, an effective intervention strategy was not instituted. The Cluster First Look Low Middle Income Trial , demonstrated this and concluded that without improvement in the quality of antenatal care, there would be limited impact in the use of routine ultrasound alone. Additionally, studies have shown 28,30identifying FGR without adequate follow up or higher quality institutional deliveries will be ineffectual in preventing stillbirths.
Studies from India have suggested the care is suboptimal at several levels 31,32At the patient level, there is failure to report decreased fetal movement, default in follow up, refusal to be hospitalised or undergo intervention, the influence of socio-cultural factors (e.g., not to report to the hospital unless spontaneous labour starts), and infrequently homebirths.
At the hospital level, causes cited included failure to manage high-risk cases, delay or error in labour management, inadequate fetal monitoring or inexperienced doctors, and the lack of equipment required for fetal surveillance in labour
Studies from Bihar33,34evaluated population-based risk factors for stillbirth. It emphasised that the INAP implementation would not be successful unless several improvements were made in obstetric care. These included improved documentation and audit, especially if delivery was deferred; 35improved quality of care, teaching women how to monitor fetal movements Additionally, communicating test results to patients, monitoring and evaluating referral practices, and increased public-private partnerships would likely lead to decreased rates of stillbirth.
Our causes of perinatal deaths echo those of the authors cited here.
In our study cohort, patients were asked to report written findings to their obstetrician which is the routine followed in most public hospitals. If, instead, time had been taken with the patient, the attendant, or the ASHA worker, to emphasise the importance of noting their due date, tracking fetal movements, returning for scheduled follow-up visits, and ensuring they understood the process of referral to a tertiary hospital, deaths may have been prevented. Franklin et al36 examined barriers to women reaching higher centres. They found that convincing women to proceed with recommendations involves critical communication, including describing ultrasound findings ,reasons for the referral, where to go in the hospital, and what to expect at the hospital.
Maternal perception of decreased fetal movements is associated with adverse pregnancy outcomes, including stillbirth 37,38Teaching patients how to monitor fetal movements is recommended in the Indian health worker guidelines for delivery of care39However the results of our study suggest that this may not be practised consistently. It has been recommended that to strengthen the surveillance mechanism to prevent stillbirths further research is needed to understand the best methods to monitor fetal movements, and what information women should receive from their providers. 40,41
We suggest that the ASHA workers be given more responsibility and be taught to check the fundal height in order to ensure appropriate hospital visits.
One suggestion to improve perinatal outcomes is to maintain a black book42 by the ultrasound clinic which contained the date of the follow-up scan and contact phone numbers of the patient, family ,neighbour and community health worker .A call was made to encourage a follow-up visit, once the recommended scan date had passed. The prevalence of cell phones, even in this strata, makes it possible to incorporate this intervention into current practice.