SASUOG envisages best possible women’s health outcomes with O&G ultrasound and Fetal Medicine services that are of high quality, accessible, appropriate, indicated, integrated and affordable.
SASUOG acknowledges that the needs are quite different for the private versus the public sector of South Africa, as they face very different challenges.
In the public sector
, the securing of sufficient funding for a well-defined care package by qualified practitioners is the main challenge, but this is restricted by severe budget limitations (esp. in terms of sonographers posts, patient transport) and poor clinical governance to implement existing policies (esp. in terms of inappropriate referrals, lack of skill).
The SASUOG Vision 2030 presented here, focuses on the private sector, esp. as it applies to the South African context, where priorities and capacity differ considerably from fully developed countries.
- The clinical value of ultrasound examinations must be improved by increasing scanning quality through improved knowledge and skill, by: Promoting accreditation, both for dating scans (both in private practice and public sector) as well as detailed fetal scans, preferably also for uterine artery Doppler and cervical length assessment (to address risks for preeclampsia, growth restriction and preterm birth). Peer-pressure (e.g. by SASOG) and hospital buy-in could be helpful.
Promoting FMF accreditation for first trimester screening as non-negotiable. It is suggested that indemnity insurers should consider professing non-coverage for non-accredited practitioners to get buy in.
Continuing to provide registrar training in fetal detail scanning, even if not requested by the COG, and in early pregnancy assessment and gynaecology pathology. Incorporating an accreditation requirement in the MMed qualifications of the different academic institutions may create the necessary incentive.
Never ending continued education via SASUOG congresses, workshops, outreach activities.
- Access to high quality ultrasound and prenatal services needs to be increased by:
Promoting development of practitioners with a “special interest” in prenatal screening scans (obstetricians or general practitioners), who could become the “go-to for routine ultrasound assessments” for a group of obstetricians linked to a specific facility or in a small town.
Ensuring adequate skill levels of qualified sonographers by getting involved in practical training and skills assessment.
Promoting the use of qualified sonographers for screening, esp. but not limited to remote areas. Telemedicine needs to be developed to support them. Adequate remuneration is required to retain them in the field of O&G ultrasound.
Increase the number of qualified subspecialists in order for them to deal with high risk pregnancies and any abnormal findings generated by any of the screening tests. We urgently need increased funding for fellowship posts in order to make full use of the existing training capacity in the different academic centres. Higher numbers will eventually saturate the metropole areas and encourage subspecialists to move outside to other large urban centres, where their impact would be substantial.
- Improving the impact of the service requires appropriate use of limited SA resources by ensuring that patients with highest risk have access to practitioners with highest level of expertise, by:
Providing patient education on risk factors and risk assessment, by developing information leaflets and/or electronic resources, involving the lay press etc.
Improving pre-screening information and counselling so parents can clarify their position towards diagnosing fetal problems and options of invasive testing and TOP BEFORE they make use of scarce screening resources. It may be feasible to train non-medical practice staff to perform this function or to engage genetic counsellors. The use of decision-aids needs to be promoted.
Promoting screening methods that are easily accessible to the vast majority of pregnant women. This includes maximal use of first and second trimester serum screening for T21 and neural tube defects and widespread use of NIPT. This would identify a substantial number of pregnancies with increased risk.
Encouraging subspecialists to run practices with large capacity to receive urgent high risk referrals due to abnormal screening investigations.
- The currently fragmented service needs to be streamlined and integrated to create maximal benefit, by:
Promoting the performance of screening investigations in low risk women by “screening practitioners” as opposed to experts.
Providing a direct and easy referral pathway for any pregnancy with abnormal screening results (according to agreed and widely circulated criteria).
Providing telemedicine support or outreach where physical referral of a high risk patient is not feasible – in order for the patient to still benefit from expert expertise, and the remote practitioner to build expertise over time.
- The service needs to be affordable for the majority of pregnant women, by:
Ensuring that the health care funders agree on generous coverage of screening for their members (even on the cheaper policy options) incl. serum screening and screening for PE and PTB etc.
Ensuring that the health care funders agree on a sustainable fee for high quality routine screening ultrasound assessments, not only for obstetricians but also for non-specialists including general practitioners with a special interest and qualified sonographers.
Ensuring that the health care funders agree on funding for indicated follow-up investigations (incl. referral to an expert, NIPT or invasive genetic testing) and genetic counselling services, according to pre-agreed criteria.
- Every O&G scan should be a high quality scan. This is best achieved if detailed fetal anatomy assessment is done by practitioners with a special interest, rather than the general obstetrician.
- Improved pre-screening counselling can help preserve scarce screening resources for those couples most likely to benefit.
- All women should have access to the expertise-level appropriate to their risk profile, as close as possible to home.
- Use of widely accessible screening tools must be actively promoted to practitioners, patients as well as funders, in order to triage effectively.
- Funders must come to the table to ensure parents can afford rational use of prenatal screening services.