Standardization and quality control of Doppler and fetal biometric ultrasound measurements in low-income setting

S Ali, J Byamugisha, M G Kawooya, I M Kakibogo, I Ainembabazi, E A Biira, A N Kagimu, A Migisa, M Munyakazi, S Kuniha, C Scheele, A T Papageorghiou, K Klipstein-Grobusch, M J Rijken

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OBJECTIVE: The aim of this study was to determine the quality of fetal biometry and pulsed-wave Doppler ultrasound measurements in a prospective cohort study in Uganda.

METHODS: This was an ancillary study of the Ending Preventable Stillbirths by Improving Diagnosis of Babies at Risk (EPID) project, in which women enroled in early pregnancy underwent Doppler and fetal biometric assessment at 32-40 weeks of gestation. Sonographers undertook 6 weeks of training followed by onsite refresher training and audit exercises. A total of 125 images for each of the umbilical artery (UA), fetal middle cerebral artery (MCA), left and right uterine arteries (UtA), head circumference (HC), abdominal circumference (AC) and femur length (FL) were selected randomly from the EPID study database and evaluated independently by two experts in a blinded fashion using objective scoring criteria. Inter-rater agreement was assessed using modified Fleiss' kappa for nominal variables and systematic errors were explored using quantile-quantile (Q-Q) plots.

RESULTS: For Doppler measurements, 96.8% of the UA images, 84.8% of the MCA images and 93.6% of the right UtA images were classified as of acceptable quality by both reviewers. For fetal biometry, 96.0% of the HC images, 96.0% of the AC images and 88.0% of the FL images were considered acceptable by both reviewers. The kappa values for inter-rater reliability of quality assessment were 0.94 (95% CI, 0.87-0.99) for the UA, 0.71 (95% CI, 0.58-0.82) for the MCA, 0.87 (95% CI, 0.78-0.95) for the right UtA, 0.94 (95% CI, 0.87-0.98) for the HC, 0.93 (95% CI, 0.87-0.98) for the AC and 0.78 (95% CI, 0.66-0.88) for the FL measurements. The Q-Q plots indicated no influence of systematic bias in the measurements.

CONCLUSIONS: Training local healthcare providers to perform Doppler ultrasound, and implementing quality control systems and audits using objective scoring tools in clinical and research settings, is feasible in low- and middle-income countries. Although we did not assess the impact of in-service retraining offered to practitioners deviating from prescribed standards, such interventions should enhance the quality of ultrasound measurements and should be investigated in future studies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Original languageEnglish
Pages (from-to)481-487
Number of pages7
JournalUltrasound in Obstetrics and Gynecology
Issue number4
Publication statusPublished - Apr 2023


  • Doppler ultrasound
  • antenatal
  • developing country
  • quality assurance
  • reliability
  • training


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