Assessing the effectiveness of decentralised antenatal ultrasound in a primary health care clinic compared with a hospital-based service in rural South Africa: an interrupted time series analysis.

BACKGROUND: Antenatal ultrasound is recommended as a routine part of care in all pregnancies by the World Health Organisation and South African National Department of Health-ideally before 24 weeks' gestation. Despite these recommendations, access to timely antenatal ultrasound is still limited in many low-resource settings, including South Africa. Decentralisation of services away from the hospital setting has been identified as a possible solution to access-related challenges. This study assessed the effect of a decentralised, primary health care based antenatal ultrasound service compared to an existing hospital-based service in a rural sub-district of the Eastern Cape of South Africa. METHODS: We conducted a retrospective, quasi-experimental, interrupted time series analysis comparing the periods before and after the implementation of a new, twice-monthly ultrasound service at a Community Health Centre. The effect of the service on timing of antenatal ultrasounds, overall uptake of ultrasounds, and antenatal care engagement was analysed. RESULTS: A total of 1239 women were included in the study period from January 2017 to July 2020 with 693 and 546 in the pre- and post-intervention periods, respectively. After the introduction of the decentralised ultrasound service, there was a significant slope change with consistent improvement over time across multiple outcomes. The proportion of women receiving ultrasounds before 24-weeks' gestation increased from 52% to 66% within 18 months of the start of the intervention, while overall uptake of antenatal ultrasounds improved similarly with monthly rates consistently above 90% at the end of the study period. Women completing four or more antenatal appointments also increased from 52% to 82%. The timing of the initial booking visit did not show any significant change. CONCLUSION: Decentralisation of an antenatal ultrasound service to a primary health care facility significantly improves timing of ultrasounds and overall engagement with antenatal care. These findings underscore the potential role of decentralised antenatal services in enhancing access to ultrasound and engagement with care.