Implementation considerations for point-of-care ultrasound for obstetric use in low- and middle-income countries: a scoping review using the Consolidated Framework for Implementation Research

Background The World Health Organization recommends that all pregnant individuals receive one ultrasound scan before 24 weeks of gestation. However, in low- and middle-income countries (LMICs), equitable access to ultrasound services is influenced by a number of community, provider and health system factors. The objective of this scoping review is to better understand facilitators and barriers to widespread adoption of obstetric point-of-care ultrasound (POCUS) in LMICs using the Consolidated Framework for Implementation Research (CFIR). Methods Guided by the PRISMA-ScR checklist, we comprehensively searched PubMed, Web of Science, and Embase for studies related to POCUS introduction and obstetric use in LMICs published between 2014 and 2023, in addition to snowball referencing. Following title and abstracts screens, we extracted data from each publication using a standard REDCap extraction form including setting/population, implementation insights, and outcome/indicators measured. We generated descriptive statistics of key characteristics and thematically mapped barriers and facilitators to the five domains of CFIR. Results Of the 917 studies initially retrieved, 53 articles met the inclusion criteria. Across the CFIR domains: (1) Intervention : the perceived relative advantage of POCUS was clinical reinforcement while a common barrier was equipment and operating costs; (2) Outer setting : cultural beliefs and social determinants of health, and the lack of clear guidelines and policies around POCUS use hindered community uptake and health system sustainability, respectively; (3) Inner setting : barriers around staffing, workload and complex referral systems were barriers to implementation, though addition of staff and POCUS documentation processes facilitated work flow integration; (4) Individuals : for clients, pregnancy and fetal reassurance was a facilitator to uptake, while limited knowledge about POCUS and late antenatal care seeking behaviors were barriers; for providers, POCUS offered confidence but workload and lack of clear protocols were barriers; (5) Process : training with continued mentorship by local trainers was an effective approach, but lack of data and referral strengthening hindered monitoring of and impact on key indicators. Conclusion By synthesizing lessons learned and the contextual nuances influencing this ecosystem using an implementation science framework, we highlight opportunities to address key barriers and to strengthen facilitators in future POCUS implementation efforts.