Incidences of fresh stillbirths and intrapartum-related asphyxia are still unacceptably high in low-resource settings . Globally, each year, an estimated 1.3 million babies are fresh stillbirths, and 700,000 early neonatal deaths occur due to birth asphyxia [2,3,4,5,6]. These perinatal deaths may be due to hypoxic-ischemic encephalopathy because of interrupted placental blood flow. To prevent intrapartum asphyxia, early detection of fetal responses to fetal hypoxemia, as indicated by fetal heart rate (FHR) abnormalities, is crucial [7, 8]. Ersdal et al. described the relationship between intermittent auscultation of FHR using a standard fetoscope and perinatal outcome. Detection of an absent or abnormal FHR was associated with fresh stillbirth or birth asphyxia, with increased need of neonatal resuscitation. In addition, as many as 40% of the babies who ended up as a fresh stillbirth had a normal or abnormal FHR on admission. These findings may reflect an inability to perform measurements correctly or as often as recommended using the fetoscope . However, intermittent auscultation of FHR, if performed as often as recommended, is regarded as safe and effective in low-risk pregnancies and birth [9,10,11].
Studies from Tanzania have also revealed that intermittent FHR auscultations using fetoscopes are not conducted according to guidelines, and that this may cause unnecessary perinatal deaths and illness [16, 17]. Based on these findings, a new affordable Freeplay Doppler was developed to meet the needs of rural settings . This Freeplay Doppler was randomly tested against the Pinard fetoscope in Uganda and in our hospital in rural Tanzania [13, 19]. The study from Uganda revealed an increased detection rate of FHR abnormalities in the Freeplay Doppler arm, but this did not translate into improved perinatal outcomes . Our study under the Safer Births project, in a rural hospital, found that abnormal FHR detection was similar between the Pinard fetoscope and Freeplay Doppler, but midwives often broke the randomization protocol by using the Pinard fetoscope instead of the Freeplay Doppler. The Safer Births project which focuses on the improvement of FHR monitoring and newborn resuscitation has been running in the hospital since 2009. The research assistants in this project have observed all births since 2009, and recorded the most commonly used device for each woman regardless of the randomization arm, and the majority of the midwives seemed to prefer the Pinard fetoscope . This contradicts with findings from other studies where professionals preferred the Doppler over the fetoscope [13, 15].
The Pinard fetoscope has been available and commonly used for decades. Midwives have gained experience in how to use it and awareness of its strengths and limitations. It also appears that knowledge and skills of using a particular device build over time. Hence, those who were exposed during midwifery training in using a device, and continued to use the same device in their work, tend to prefer that device.
Personal hearing and counting the FHR were perceived by midwives as important aspects of feeling confident about the measurements when using the Pinard fetoscope. In addition, some midwives found it easy to discover FHR abnormalities.
The midwives participating in these FGDs had different views regarding the two devices (Pinard fetoscope and Freeplay Doppler), and the FGDs did not reveal a common clear predilection for one of the devices. Based on their opinions, three main themes emerged as important factors affecting user preference; 1) sufficient training and experience in using a device, 2) the perceived ability to produce reliable (accurate) measurements, and 3) the convenience of use and comfort of the device.
Fetoscopes are the most common devices used to monitor FHR in low-resource settings, much more common than Dopplers. Fetoscopes have been in use for decades, need no electricity, and are highly portable and relatively inexpensive; hence, they are easily available for use in both training institutes and facilities in low-resource settings . Midwives clearly pointed out that having adequate pre-service training and many years of clinical experience in using fetoscopes made them feel confident; thus, they preferred to use this device. Knowledge is acquired over time, and some midwives said they trusted the Pinard fetoscope more than the Freeplay Doppler because they had more experience in using the Pinard fetoscope. They were more confident about their own auscultations and measurements using the Pinard fetoscope than they were simply watching the numbers produced by the Freeplay Doppler. However, they emphasized that this uncertainty was likely caused by inadequate training, knowledge, and experience in using the Freeplay Doppler.
The study managed to get detailed information about feelings and perceptions of both groups and individual midwives through the FGDs. Our study was part of the larger Safer Births project, and the findings explain the gaps in the previous randomized study, which found many crossovers, with the Pinard fetoscope being used more than the Freeplay Doppler . FGDs were moderated by three moderators with different backgrounds (an obstetrician, a senior nurse midwife, and a clinical psychologist). This mix of backgrounds and professional experiences made it easy to capture most of the study objectives, and the midwives were free to express their opinions. Both manual records and a computer software (NVivo 11 program) were used during analysis, making the analysis exhaustive enough to capture all aspects of the discussion.
One benefit of using a fetoscope over a Doppler machine is that it is not an ultrasonic device, so it does not carry the same potential risks. However, like with a Doppler machine, a person should not panic if they do not hear a heartbeat, as long as they feel the baby moving. 59ce067264