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.