Prof. Eik-Nes and Tegnander discuss the crucial role of midwives in supporting pregnant women and their offspring, emphasizing the growing importance of ultrasound in their practice. Focusing on Norway and South Africa, it highlights similarities in midwifery education programs and highlights the benefits of incorporating ultrasound training in South Africa to address rural populations' needs. This inclusion not only benefits communities but also offers environmental advantages.

Midwives have always been involved in the work of caring for and supporting pregnant women and their developing offspring. The introduction of ultrasound in prenatal care has made it possible to learn about the development of the fetus in utero, making it especially relevant for midwives in their striving to prevent morbidity and mortality of the fetus/neonate and the mother.

Midwives’ use of ultrasound in pregnancy varies from country to country. In this text, the focus is on midwives’ education and use of ultrasound in developed countries – with Norway as an example - and in low-and middle-income countries (LMIC) – with South Africa as an example. Both Norway and South Africa are characterized, in part, by dispersed rural populations with long distances between people and health care services.

In Norway, as in the other Scandinavian countries (Sweden, Finland, Denmark, Iceland), midwives traditionally hold the responsibility for following and supporting women throughout their pregnancies. Midwives are also responsible for all deliveries, regardless of whether they take place in hospitals or local wards where distances to hospitals are long and difficult. Doctors normally take part in deliveries only when there is a need for attention by a specialist.

In rural South Africa, midwives are responsible for following and supporting women throughout their pregnancies. They attend to all deliveries in the Public Health Clinics (PHC) where there are no doctors. They are also responsible for deliveries at the next level of care, the Community Health Centers (CHC), where doctors are sometimes available. Midwives in rural South Africa are also often involved in other community health tasks, such as vaccination programs and other duties that demand attention but are not directly related to pregnancy care.

Midwives in rural South Africa are recognized for their important role in society, as evidenced by Nelson Mandela’s encouragement to empower those who refrained from leaving South Africa after apartheid. While many doctors left for better conditions, midwives were more likely to stay in their home areas and continue to care for their people. The focus on educating midwives increased, marking the start of our education of midwives in ultrasound. In 2001, we were contacted by Chief Director of Maternal, Child & Women’s Health, National Department of Health in South Africa, Dr Roland Edgar (Eddie) Mhlanga, who had learned about our work as a WHO teaching and training centre for ultrasound in obstetrics and gynecology in low- and middle-income countries. We were invited to the province of KwaZulu-Natal in South Africa to explore and support midwives’ use of ultrasound in rural areas and to establish education in ultrasound for midwives.

While there are variations, education programs for midwives in Norway and South Africa are quite similar. In Norway, a midwife must first complete a full nursing education (3 years). After one year of practice, a nurse may opt to pursue a degree in midwifery (2 years). After yet another year of practice, the midwife may pursue a degree to become a qualified specialist through the Postgraduate Ultrasound Education for Midwives we have established at the Norwegian University of Science and Technology in Trondheim. This one-year education comprises a total of 10 weeks of attendance at the university, with the remainder of the year at the students’ home institutions for practical work. This postgraduate program is the only educational program in Norway that provides specialization in medical ultrasound.

In South Africa, midwives are also qualified nurses (3 years) prior to their education as midwives (1 year), followed by an additional 2 additional years to become advanced midwives. We have adapted the Norwegian Postgraduate Ultrasound Education for Midwives to the needs of South African midwives in rural areas. The education is a full year, beginning with 4 weeks of theoretical and practical learning at a central institution. Following this, midwives spend 4 months working at their home clinics, where they apply ultrasound techniques as part of pregnancy care. The midwives return to the central institution for a 2-week period of more theory and practical learning, before resuming work at their home institutions for 6 months. Finally, they reconvene again for a final 2-week session at the central institution.

The importance of using ultrasound to examine the fetus during pregnancy – regardless of the country in – is to reduce the morbidity and mortality of the fetus and the mother. Through their continuous contact with pregnant women, midwives develop a wealth of knowledge and insight into the progress of a pregnancy and the well-being of the fetus and the mother. Adding ultrasound competency to their already well-developed knowledge of pregnancy care empowers the midwives in their roles and provides pregnant women with a high level of care, even in rural areas.

When used by trained personnel, i.e. midwives, important information about the fetus can be obtained. This information includes number of viable fetuses, possibly missed abortion, gestational age, fetal growth, position of the placenta, breech presentation, amount of amniotic fluid and an overview of the anatomy of the fetus. This information is significant in the care of the fetus and the mother, especially in rural areas where specialists are few and far between.

Ultrasound examinations provide visual information that cannot be obtained without ultrasound. Identifying any condition that needs attention at an early stage makes it possible to refer the pregnant woman to a hospital as soon as possible to treat the condition or avoid complications. Without ultrasound, such fetal or maternal problems are difficult or impossible to detect, and thus not referred – or referred too late to help the fetus and/or the mother. Placenta previa is one condition that, if undetected prior to delivery, may lead to the death of both the fetus and the mother.

Furthermore, information gleaned through ultrasound enables the midwife to differentiate between suspected complications and actual complications. Through ultrasound, the suspected complication can be confirmed or dismissed. If dismissed, the pregnant woman does not have to go through being transported on poor roads and long distances unnecessarily. Avoiding unnecessary transportation also has significant advantages from an economic and environmental point of view. Unnecessary referrals constitute a waste of resources at the receiving hospital. Data show that after the introduction of ultrasound performed by midwives in rural areas, the number of (unnecessary) referrals has decreased.

In South Africa, the rate of women who have died after illegal abortions was extremely high. After abortion became legal, midwives have also taken on the task of performing legal abortions. The ability to examine the fetus and uterus via ultrasound prior to performing an abortion has made the procedure safer.

Collaboration between OBGYN specialists and ultrasound-educated midwives is mainly a matter of task sharing rather than collaboration. Midwives use their knowledge of pregnancy and the insight they derive from the ultrasound examination to describe the fetus and the progression of the pregnancy, and then to deliver the baby. They can carry out their tasks with greater confidence in their knowledge. OBGYN specialists are consulted only when necessary.

Including ultrasound as part of the basic education of midwives is questionable. It is important that midwives learn about ultrasound, its use and its importance in pregnancy care in their basic education. However, we do not recommend including a full ultrasound education as part of the basic education for midwives. Firstly, the work of a midwife covers many areas. Introducing education in ultrasound at a level in which midwives can effectively use it for the benefit of the pregnant woman and the fetus would mean either leaving out important areas of midwifery or extending the duration of midwifery education. There are many specialties in midwifery, and ultrasound should be considered a specialty, rather than a component of basic education.

Written by:

Professor Sturla H. Eik-Nes, Professor emeritus, NTNU. Honorary Professor, Nelson Mandela School of Medicine, Obstetrics and Gynecology University of KwaZulu-Natal, Durban, South Africa

Eva Tegnander, Ultrasound midwife/ Sonographer PGCert./Associate ProfessorProgram director, Postgraduate ultrasound education for midwives, National Center for Fetal Medicine, Norwegian University of Science and Technology, Trondheim Norway