Antenatal Tele-Ultrasound

In Bangladesh Family Welfare Visitors (FWV) with basic training provide minimal antenatal care (ANC) in rural areas, referring expectant mothers to Government facilities for delivery and in complex cases. However, many mothers still have deliveries at home, not taking advantage of such facilities, possibly because of lack of trust in FWVs. Our solution will engage trained operators to support FWVs in providing improved ANC. Our operators will acquire fetal images using low cost portable ultrasound scanners under real time guidance of remote sonologists through the internet. Based on the clinical scenario and ultrasound report, the pregnant mothers will be offered telemedicine consultation with expert obstetricians if needed. Through this solution the FWV will be able to offer improved ANC and thus generate trust in Government facilities reducing maternal and childhood mortality. Similar situation exists in all LMICs and our solution, if scaled, will save a lot of lives globally.

In 2017, the maternal mortality rate in Bangladesh was 173 per 100,000 live births, the global figure being 211 and the SDG goal being 70. Pregnant women taking at least one ANC was about 82% while those taking suggested four ANCs was about 47%. The figures would be lower in rural areas where 65% of the population of about 170 million live. At the lowest level of the infrastructure, the Government has appointed Family Welfare Visitors (FWV). With an educational background of secondary level followed by 18 months of training, they provide antenatal care (ANC) besides other related activities, referring pregnant mothers to sub-urban health facilities for complications and for delivery. Understandably this falls short of the desired quality and a lack of trust prevails due to which many mothers still have deliveries at home, not taking advantage of Government facilities. Overall slightly above 50% of deliveries are done in facilities having at least a minimum of trained personnel, the rest are done at home by traditional untrained or slightly trained attendants, relatives and friends. Situations in some Sub-Saharan African countries are worse. Besides, neonatal death, neonatal health, also depends a lot on maternal antenatal care. 

Our solution will engage trained operators at Union Health and Family welfare centers(UHFWC), the lowest level of infrastructure provided by Bangladesh Government, to acquire fetal images of pregnant women using low cost and portable smartphone based ultrasound scanners, under real time guidance of remote sonologists through the internet. So a minimally trained operator will be able to perform the task. This will be designed to support FWVs appointed in these centers. Based on the clinical scenario and ultrasound report, the pregnant mothers will be offered telemedicine consultation with expert obstetricians if needed. Thus FWVs will be able to offer improved ANC, generate trust and motivate expectant mothers into increasing their visits to the centers. This in turn will allow for enhanced service delivery and timely intervention due to higher attendance. Thus, it will be possible to give quality ANC to an expectant mother in rural areas close to her home, allowing a quicker achievement of SDG in terms of maternal and neonatal mortality and healthcare. If successful, this model may be replicated to other LMICs globally.

The proposed solution will serve the women of childbearing age and the expectant mothers of the catchment area of the rural UHFWCs in Bangladesh, whose ANC needs are well understood through many research activities done in the past. During this project period, 10 UHFWCs will be covered, having a total population of about 250,000 with about 4500 pregnancies per year. The FWVs deployed by the Government at these centres have limited knowledge and experience in ANC, which will be supplemented by a modern technology such as the ultrasound scanner and the knowledge and experience of qualified Sonologists and obstetricians through telemedicine. The ultrasound operators engaged in this project will also double as data collectors for the areas concerned. They will also link to the local women to understand their needs better. For comparison, data will be collected from a similar number of neighbouring areas where intervention such as ours is not in place engaging other personnel. We expect to generate confidence in the women of the catchment areas in taking the services provided by the UHFWCs contributing to a reduction in maternal and neonatal mortality. This will also be documented through our acquired data and its analysis.

The challenge relates to maternal and newborn health in rural areas of Bangladesh where 65% of the population lives but not qualified doctors. Government efforts through less qualified FWVs have improved the situation over the years but still has not been able to achieve the full trust of the target population. Bangladesh has almost full coverage of mobile phone networks and 3G internet. Therefore, our solution utilising mobile phone based ultrasound scanning and telemedicine through the internet, will improve ANC offered by FWVs and will also motivate the women to utilise established facilities for ANC and delivery.

Ultrasound technology is widely used for ANC in the world but unfortunately, a majority of the global population living in rural areas of LMICs like Bangladesh remain deprived. Furthermore, qualified medical doctors are not available to these rural people due to socio-economic reasons. As mobile phone  and internet coverage increased in Bangladesh, our group has been working since 2011 in developing an indigenous capability in telemedicine that includes both software and online digital diagnostic devices like stethoscopes and ECG equipment. After two years of field trial we deployed the service throughout Bangladesh in 2015 under the name, ‘Dhaka University Telemedicine Programme’’ taking necessary permissions. So far we provided more than 30,000 patient consultations through 50 rural centres. We received several national and international awards so far, two of these as ‘Winners’. 

Low cost ultrasound scanners based on mobile phones have started coming into the commercial arena only recently.  Although we did not develop this item ourselves, we planned to add it to our telemedicine system. Procuring a low cost one from overseas suppliers we tested its efficacy in pregnancy profiling (number of fetus, cardiac pulsation and fetal movement, fetal biometry, gestational age, placental location, amniotic fluid volume and presentation of the fetus), comparing the results with that from a standard equipment. As the outcome was highly satisfactory, we now plan to use this technology, together with our telemedicine platform, in a few rural areas of Bangladesh to improve ANC.  No other group has the experience with similar indigenous systems.

The core technology behind our solution is ultrasound scanning and telemedicine through internet. Ultrasound technology is widely used  for detection of pathology and pregnancy profiling. However, standard ultrasound scanners are unaffordable and impractical in the rural areas of LMICs like Bangladesh. Besides, it is not possible to retain qualified sonologists and obstetricians in the villages. Therefore, we are using a low cost mobile phone based ultrasound scanner, which appeared in the market relatively recently, together with our own telemedicine network to provide antenatal care to the expectant mothers of rural Bangladesh. These scanners are easy to operate. A minimally trained operator will hold the scanner on the subject under real-time video guidance of a remote sonologist. This guidance for positioning of the device will be acceptable even if the network bandwidth is not adequate. Images will then be stored and forwarded to the sonologist and to an obstetrician, if needed, for their reports. 

Our planned model of deployment complements the existing infrastructure of the Government; not competes against. Our operator will work at the premises of a Family Welfare Visitor (FWV) of the Government in rural areas. FWVs have minimal education and training and have not been able to earn the full trust of pregnant mothers. Therefore ANC visits remain less than desired. Through the reports based on ultrasound scans the FWV will be able to provide improved ANC and earn trust of the beneficiaries. This model of intervention has not been tried before.

Our group has been working since 2011 in developing an indigenous capability in telemedicine that includes both software and online digital diagnostic devices like stethoscopes and ECG equipment. After two years of field trial we deployed the service throughout Bangladesh in 2015 under the name, ‘Dhaka University Telemedicine Programme’’ taking necessary permissions. So far we provided more than 30,000 patient consultations through 50 rural centres. We received several national and international awards so far, two of these as ‘Winners’. 

Low cost ultrasound scanners based on mobile phones have started coming into the commercial arena only recently.  Although we did not develop this item ourselves, we planned to add it to our telemedicine system. Procuring a low cost one from overseas suppliers we tested its efficacy in pregnancy profiling (number of fetus, cardiac pulsation and fetal movement, fetal biometry, gestational age, placental location, amniotic fluid volume and presentation of the fetus), comparing the results with that from a standard equipment. The outcome was highly satisfactory.

Link to an under preparation abstract:

https://drive.google.com/file/d/1n4-IokMuJxPTgWoe1pRI4b0ZAWUf3-vI/view?usp=sharing

Link to a published abstract:

https://drive.google.com/file/d/13O70y73SRfNvEy_ak79CSBsi-KnT1xZe/view?usp=sharing

(in the Souvenir of the International Conference of Physics in Medicine- 2020, Dhaka, Bangladesh).

Rural people in LMICs like Bangladesh have remained ever deprived of the benefits of modern technology, particularly in healthcare. For example, X-ray and ECG, two vital technologies in healthcare were invented more than a century back, but the majority of people in rural areas and in small townships in Bangladesh do not get the benefits of these devices still now. Therefore, seeking interventions from appropriate modern technology can bring a positive change in the scenario. Our telemedicine technology together with the digital stethoscope and ECG for online transfer of data are all developed by our group indigenously. With a minimum of funding we deployed our telemedicine in rural areas of Bangladesh since 2015 and so far could provide more than 30,000 patient consultations through qualified medical practitioners living in the cities. More than 75% of these patients were women, children and elderly, and most of them would not have taken a proper doctor’s consultation had our telemedicine centres were not there. Many other groups are trying telemedicine, but most of these target city people as they are ready to pay money for doctors’ consultation. On the other hand people in the village are not used to paying consultation fees. They get it free from a drug seller or from a village quack, but paying more for the medicines, besides getting maltreatment in most cases. We could bring some changes in this scenario as we charge the patients a certain amount of fee to cover the expenses. 

In the present proposal we plan to complement Bangladesh Government’s initiatives in improving ANC in the rural areas through FWVs, as outlined in previous answers. If we succeed in this programme, definitely it will bring a big change in ANC of the rural population. This can be scaled up in Bangladesh as well as in other LMICs of the world.

Our present telemedicine service has provided patient consultation to about 30,000 people in the last 4 and a half years. Since we charged a fee the number remained low. If we could provide free consultations, the number would have been many times more. In the present effort, we will work with the Government where most of the services are free. We will also cover our expenses through this project funding, charging nothing to the patients. So we expect to reach out to most people that we will cover as mentioned below.

We will cover 10 Unions (lowest administrative unit in Bangladesh), each having a population of about 25,000. So in all we will cover a population of about 250,000. Considering a 2% birth rate, we may expect to get about 5000 pregnancies in the 12 months of the active part of the project period, and they will be served directly through our programme.

Subsequently, if funds are available or if the Government approves this model of intervention, this may cover the whole of Bangladesh in the next five years, covering all the 170million people and about 3.5 million births. If this model is replicated in other LMICS, the benefit will be reaching several billions of people globally.

We will cover 10 Unions (lowest administrative unit in Bangladesh), each having a population of about 25,000 in the next year. So in all we will cover a population of about 250,000. Considering a 2% birth rate, we may expect to get about 5000 pregnancies in the 12 months of the active part of the project period, and they will be served directly through our programme.

Subsequently, if funds are available or if the Government approves this model of intervention, this may cover the whole of Bangladesh in the next five years, covering all the 170million people and about 3.5 million births. If this model is replicated in other LMICS, the benefit will be reaching several billions of people globally.

Governmental approval.

Financial.

Getting Sonologists and Obstetricians.

Recruiting and training of ultrasound operators.

Maintenance of the Ultrasound scanners. 

Maintenance of Telemedicine platform.

Governmental approval:  We have permission from the Government to operate telemedicine services throughout Bangladesh, therefore, this will not pose so much of a barrier. We will be talking to the appropriate directorates for integrating our services to theirs, which may take some time in getting over the formalities.

Financial: Getting the project funding will remove the barrier for the first year. Within this time we will work with the Government and other agencies for financial support to continue the work further. Considering the impact of the work, we are higjly hopeful

Getting Sonologists and Obstetricians: We already have a sonologist with our team. Besides, many female doctors take maternity leaves when they can work from home on the telemedicine programme. We need only two sonologists and one obstetricians during this project period, which will not be difficult to find.

Getting ultrasound operators: We will recruit females with a higher secondary background and train them up. There is a lot of unemployment in the country, so it will not be a problem.

Maintenance of the Ultrasound scanners: We will procure these from a chinese manufacturer and will procure a few more devices initially to replace out of order ones immediately. Besides, we will try to get service manuals from the manufacturers.

Maintenance of Telemedicine platform: This is our technology, so there is no problem in maintaining this part.

University department. We belong to the Department of Biomedical Physics & Technology of the University of Dhaka. The Project lead was the founder chairperson of this department from 2008 to 2015. After his retirement in 2015, he continues to lead several research projects of the department including ‘Dhaka University Telemedicine Programme’, being appointed as an Honorary Professor.

Full time management and research staff (combined role): 5

Part time research staff: 3

Local entrepreneurs, operating telemedicine centres: 50 

 Doctors: 20

The project lead obtained a PhD in Microelectronics from University of Southampton, UK in 1978. There he realised that without indigenous technology solutions, the quality of life of the common people in Bangladesh will not improve, they will remain ever deprived. In spite of lucrative job offers abroad he came back home straight. Since then he has been working ceaselessly in developing technology that will enhance the quality of life of the common people in LMICs like Bangladesh, who constitute the majority of the global population. Over these years his team, with a couple of seniors, could organise a link with Sheffield University, UK, which allowed his team to acquire the expertise to design and develop computer interfaced electromedical equipment. Through these  years the project leads supervise more than 100 Masters students and about a dozen PhD and MPhil students, and some of them stayed with him, continuing as research fellows and bringing with them recent technologies like IOT, embedded systems, etc., and expertise in modern software. Besides, the project leader, through his lifelong experience, knows the country and its people well, he knows how they react, their culture, special behaviour, etc. All these makes this group eminently suitable to take up a challenge as proposed.

At Dhaka University the project lead founded the postgraduate Department of Biomedical Physics & Technology (BMPT) in 2008, as mentioned before, solely targeting application oriented research. Thus teachers and students of this department were imbibed with his philosophies and together with some of them he founded BiBEAT Ltd., in 2013, which is a non-shareholding company aiming to manufacture and distribute technologies developed at BMPT or by others locally. Prior to that, in 1996, he also founded ‘Relevant Science & Technology Society, Bangladesh (RSTS)’ taking along groups of colleagues and students. ‘Relevant Science & Technology Institute (RSTI)’ is an institute which they formed recently under RSTS. The purpose of RSTI is to take up innovations from BMPT and turn them into disseminable products, either commercially or non-commercially, and also take up the dissemination process for the latter. Thus BMPT, RSTI and BiBEAT form a triangular eco-system which would be a model for any LMIC. 

The eco-system thus established has achieved successes which dwarf that of many others employing many more scientists and spending many times the expenses.

Ours is an University department. We get some research funding from the University itself, however, our major funding comes from the International Science Programme of Uppsala University, Sweden. Besides, for Telemedicine, we initially had some funding from a Bangladesh Government innovation fund, and later we got some donations from so we still have to depend on some donations, but organisations or individuals.However, we are gradually working to become self-sustaining, charging fees from patients and have come a long way in this regard. Interestingly, we did not ask any money from the university for this programme except for its permission to use its name and logo. Eventually, the telemedicine programme will be taken up by our sister organisation RSTI, or BiBEAT Ltd, which were introduced in the previous answer.

AT present, the proposed project will be funded by the expected grant and prizes from MIT Solve. However, in future, we expect that the Government will be interested in this project and will either support us financially, or take up our solution into its own programme.

Our main barrier is that of finance as mentioned in the section on barriers. If MIT-Solve provides us the USD 100,000 asked for, we hope to use this amount to convince our Government and others so that this model of service is perpetuated in Bangladesh and in other LMICs.

We will need partners to take this project to other LMICs of the world. So we need product/service distribution partners.

For funding the above and for the expanded revenue model, we need partners.

For legal or regulatory matters in other countries, we will need partners.

No specific names. Any one who can promote our solution to other LMICs through securing necessary funds will be welcome to partner with us.

Our work directly strengthens the health workforce so that they can create a major impact in the lives of women and newborns. If proper antenatal care is given to pregnant mothers they will contribute to reduced maternal and neonatal mortality besides, good health for both. Our project model will expand access to training for health workers in the use of ultrasound scanners and telemedicine, through which the assessment and referral capabilities of the rural family welfare visitors (FWV) will be improved.

If we can succeed in the proposed model in Bangladesh, which is an LMIC itself, this model can be expanded in the whole of Bangladesh and to the whole of the LMICs, particularly for their rural population, which form the majority and who remains deprived of many basic needs of life because of complex socio-economic reasons. Therefore, we are immensely qualified for this prize. 

We will use the innovation prize to organise this new service model proposed. This will involve recruiting and paying remunerations of 10 ultrasound/telemedicine operators, two Sonologists, One Obstetrician and a few management and data collection personnel, procurement of necessary equipment, and for travel, data analysis, etc. The project will run for 18 months with active service to patients for 12 months. The rest will be used for recruitment, training, data collection, analysis and reports. 

Our project aims at working hand in hand with Government appointed  rural family welfare visitors (FWV) such that their assessment and referral capabilities are improved significantly. For this we will have to work closely with the Government and our project aims at building trust and confidence of the pregnant women in the rural areas in the infrastructure that our Government has created. As mentioned, about half of the pregnant mothers still do not take advantage of facilities of delivery that have been established by the Government, private organisations and NGOs, supported by trained medical staff. Therefore, with the improved service through ultrasound scanning and telemedicine, the women in the rural areas will have confidence in the public system, will take te required number of antenatal care visits, and have deliveries at public facilities. 

If we can succeed in the proposed model in Bangladesh, which is an LMIC itself, this model can be expanded in the whole of Bangladesh and to the whole of the LMICs, particularly for their rural population, which form the majority and who remains deprived of many basic needs of life because of complex socio-economic reasons. Therefore, we are immensely qualified for this prize. 

We will use the innovation prize to organise this new service model proposed. This will involve recruiting and paying remunerations of 10 ultrasound/telemedicine operators, two Sonologists, One Obstetrician and a few management and data collection personnel, procurement of necessary equipment, and for travel, data analysis, etc. The project will run for 18 months with active service to patients for 12 months. The rest will be used for recruitment, training, data collection, analysis and reports. 

At the end of this project period, we would expect further grants to expand our model to other LMICs of the world, with support from Governments in those countries as well.