Evaluation of a tele-ultrasound training program for high-risk pregnancy screening in rural Madagascar: a mixed-methods implementation study
Abstract
This work was presented at the Geneva Health Forum 2026, Geneva, Switzerland. Introduction: Prenatal ultrasound improves detection of high-risk pregnancies but access remains limited in low-resource settings, including Madagascar. Task-sharing combined with telemedicine may expand access by enabling non-specialist providers to scan under remote supervision. The MaMEcho (Madagascar-Mère-Enfant-Échographie) project implemented a hybrid in-person and tele-supervised training programme in rural Ambanja district, targeting six obstetric risk conditions (fetal presentation, placental position, amniotic fluid index, fetal viability, fetal growth, and multiple pregnancy) to support referral. This study assesses training effectiveness, image acquisition skills and programme acceptability. Methods: We conducted a mixed-methods implementation evaluation. Quantitative outcomes (theoretical knowledge, image quality progression, expert validation rate, acceptability) were analysed with descriptive statistics and mixed-effects regression models. Qualitative data (participants' experience) were analysed thematically. Results: Twelve providers (10 midwives, 2 physicians) at eight facilities were trained by 6 experts; 75 partner patients joined workshops and 734 pregnant women were scanned under remote supervision. Mean knowledge score increased from 31.5/40 at T0 by +6.4 points at T1, remaining +6.0 points above baseline at T2. Mean initial image quality was 20.75/25, with a significant but modest progression of +0.30 points per 10 examinations. Of 192 examinations with trainee-reported high-risk findings, 173 (90.1%) were expert-validated. Patient acceptability was high (99.7% found the examination useful; 98.2% would repeat it). Trainees were satisfied with the training format and materials; insufficient practical time and unstable connectivity were the main concerns. Discussion: The MaMEcho hybrid programme is feasible and well accepted in rural Madagascar, offering a promising strategy to strengthen prenatal risk screening where specialist access is limited. Keywords: Tele-ultrasound, Point-of-care ultrasound (POCUS), Task-sharing, Midwifery, High-risk pregnancy, Implementation science, Low- and middle-income countries (LMICs), Madagascar
