African Journal of Public Health and Health Systems | 20 November 2024

A Methodological Framework for Integrating Midwife-Led Point-of-Care Ultrasound into Routine Obstetric Care in Rwandan District Hospitals

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Abstract

<strong>Background:</strong> Integrating point-of-care ultrasound (POCUS) into routine obstetric care can address critical diagnostic gaps. In Rwanda, a shortage of specialist sonographers at district hospital level necessitates task-shifting to midwives. A systematic methodology for implementing this service sustainably is required. <strong>Purpose and objectives:</strong> This article details a structured methodological framework for implementing midwife-led obstetric POCUS in Rwandan district hospitals. Its objective is to provide a replicable, stepwise approach covering training, clinical integration, quality assurance, and sustainability. <strong>Methodology:</strong> Developed and refined between 2021 and 2024, the framework uses an implementation science approach, guided by the Consolidated Framework for Implementation Research (CFIR). It comprises five phases: (1) pre-implementation stakeholder engagement and site readiness assessment; (2) competency-based training and mentorship of midwives; (3) phased clinical integration with standardised scanning protocols; (4) establishment of a digital image archiving and peer-review system for quality assurance; and (5) fostering local ownership and developing monitoring and evaluation plans. <strong>Key insights:</strong> Framework development underscored that continuous clinical mentorship is crucial for success. Initial pilot data (2023-2024) indicated that with structured support, over 85% of trained midwives achieved competency in basic obstetric scans. A key operational challenge was integrating scan requests into existing midwifery workloads. <strong>Conclusion:</strong> This framework provides a practical, theory-informed methodology for scaling midwife-led POCUS in Rwanda and similar settings. It systematically addresses implementation barriers including sustainable training, quality control, and health system integration. <strong>Recommendations:</strong> Implementing bodies should adopt this phased framework, prioritising sustained mentorship over isolated training. Policymakers should consider formal credentialing mechanisms for midwife sonographers to support professional recognition and service sustainability. <strong>Key words:</strong> implementation science, point-of-care ultrasound, midwifery, task-shifting, obstetric care, Rwanda, district hospitals <strong>Contribution statement:</strong> This methodology provides a structured, context-specific framework for integrating midwife-led point-of-care ultrasound into routine obstetric services in low-resource district hospitals, with a focus on sustainable implementation.