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Open Access 19-04-2024 | Echocardiography | Review

Initiating a Fetal Cardiac Program from Scratch in Low- and Middle-Income Countries: Structure, Challenges, and Hopes for Solutions

Author: Shaimaa Rakha

Abstract

Although fetal cardiac programs are well established in developed countries, establishing an efficient program in low- and middle-income countries (LMICs) is still considered a significant challenge. Substantial obstacles usually face the initiation of fetal cardiac service from scratch in LMICs. The primary structural frame of a successful fetal cardiac program is described in detail, emphasizing the required team members. The potential challenges for starting fetal cardiac services in LMICs include financial, awareness-related, prenatal obstetric screening, sociocultural, psychosocial, and social support factors. These challenges could be solved by addressing these barriers, such as collecting funds for financial support, raising awareness among families and health care providers, telemedicine, building international health partnerships, modifying training protocols for fetal cardiologists and sonographers, and initiating support groups and social services for families with confirmed fetal cardiac disease. Initiating a successful fetal cardiac program requires multi-aspect structural planning. The challenges for program initiation require diverse efforts, from modified training and promoting awareness of care providers and the community to governmental and nonprofit organizations’ collaborations for proper building and utilization of program resources.

Winsberg F (1972) Echocardiography of the fetal and newborn heart. Investig Radiol 7(3):152–158. https://doi.org/10.1097/00004424-197205000-00004CrossRef

Chambers Gurson S (2019) Advances in fetal echocardiography: myocardial deformation analysis, cardiac MRI and three-dimensional printing. Curr Opin Cardiol 34(1):35–40. https://doi.org/10.1097/HCO.0000000000000584CrossRefPubMed

Gardiner HM (2018) Advances in fetal echocardiography. Semin Fetal Neonatal Med 23(2):112–118. https://doi.org/10.1016/j.siny.2017.11.006CrossRefPubMed

Halder V, Ghosh S, Shrimanth YS, Manoj RK, Mandal B, Thingnam SKS, Kumar R (2021) Fetal cardiac intervention and fetal cardiac surgery: where are we in 21st century? Am J Cardiovasc Dis 11(5):642–646PubMedPubMedCentral

Kumar S, Lodge J (2019) Prenatal therapy for fetal cardiac disorders. J Matern Fetal Neonatal Med 32(22):3871–3881. https://doi.org/10.1080/14767058.2018.1472224CrossRefPubMed

Mustafa HJ, Aghajani F, Jawwad M, Shah N, Abuhamad A, Khalil A (2023) Fetal cardiac intervention in hypoplastic left heart syndrome with intact or restrictive atrial septum, systematic review, and meta-analysis. Prenat Diagn. https://doi.org/10.1002/pd.6420

Zheleva B, Atwood JB (2017) The invisible child: childhood heart disease in global health. The Lancet 389(10064):16–18CrossRef

Sachdeva S, Ramakrishnan S (2022) Fetal cardiology in India—at the crossroads. Ann Pediatr Cardiol 15(4):347–350. https://doi.org/10.4103/apc.apc_156_22CrossRefPubMed

Zühlke L, Lawrenson J, Comitis G, De Decker R, Brooks A, Fourie B, Swanson L, Hugo-Hamman C (2019) Congenital heart disease in low- and lower-middle-income countries: current status and new opportunities. Curr Cardiol Rep 21(12):163. https://doi.org/10.1007/s11886-019-1248-zCrossRefPubMed

10.

Liu Y, Chen S, Zühlke L, Black GC, Choy MK, Li N, Keavney BD (2019) Global birth prevalence of congenital heart defects 1970–2017: updated systematic review and meta-analysis of 260 studies. Int J Epidemiol 48(2):455–463. https://doi.org/10.1093/ije/dyz009CrossRefPubMedPubMedCentral

11.

GBD 2017 Congenital Heart Disease Collaborators (2020) Global, regional, and national burden of congenital heart disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Child Adolesc Health 4(3):185–200. https://doi.org/10.1016/S2352-4642(19)30402-XCrossRef

12.

Zhang YF, Zeng XL, Zhao EF, Lu HW (2015) Diagnostic value of fetal echocardiography for congenital heart disease: a systematic review and meta-analysis. Medicine (Baltimore) 94(42):e1759. https://doi.org/10.1097/MD.0000000000001759CrossRefPubMed

13.

Rakha S, El Marsafawy H (2019) Sensitivity, specificity, and accuracy of fetal echocardiography for high-risk pregnancies in a tertiary center in Egypt. Arch Pediatr 26(6):337–341. https://doi.org/10.1016/j.arcped.2019.08.001CrossRefPubMed

14.

Moon-Grady AJ, Donofrio MT, Gelehrter S, Hornberger L, Kreeger J, Lee W, Michelfelder E, Morris SA, Peyvandi S, Pinto NM et al (2023) Guidelines and recommendations for performance of the fetal echocardiogram: an update from the American Society of Echocardiography. J Am Soc Echocardiogr 36(7):679–723. https://doi.org/10.1016/j.echo.2023.04.014CrossRefPubMed

15.

Holland BJ, Myers JA, Woods CR Jr (2015) Prenatal diagnosis of critical congenital heart disease reduces risk of death from cardiovascular compromise prior to planned neonatal cardiac surgery: a meta-analysis. Ultrasound Obstet Gynecol 45(6):631–638. https://doi.org/10.1002/uog.14882CrossRefPubMed

16.

Yonehara K, Terada K, Morine M (2022) Impact and problems of fetal echocardiography: a single-institution study in Japan. Cureus 14(11):e31423. https://doi.org/10.7759/cureus.31423CrossRefPubMedPubMedCentral

17.

Vaidyanathan B, Rani K, Kunde F, Thomas S, Sudhakar A, Kumar RK, Zheleva B (2022) Prenatal diagnosis lowers neonatal cardiac care costs in resource-limited settings. Cardiol Young 32(11):1754–1760. https://doi.org/10.1017/S104795112100487XCrossRefPubMed

18.

Vijayaraghavan A, Sudhakar A, Sundaram KR, Kumar RK, Vaidyanathan B (2019) Prenatal diagnosis and planned peri-partum care as a strategy to improve pre-operative status in neonates with critical CHDs in low-resource settings: a prospective study. Cardiol Young 29(12):1481–1488. https://doi.org/10.1017/S104795111900252XCrossRefPubMed

19.

Donaghue D, Rychik J (2006) The fetal heart program: a multidisciplinary practice model for the fetus with congenital heart disease. Prog Pediatr Cardiol 22:129–133. https://doi.org/10.1016/j.ppedcard.2006.01.014CrossRef

20.

Buzzard CJ (2005) Implementation of a fetal cardiology comprehensive program at a moderate sized University Medical Center. Prog Pediatr Cardiol 20(1):39–44. https://doi.org/10.1016/j.ppedcard.2004.12.003CrossRef

21.

Smythe JF, Copel JA, Kleinman CS (1992) Outcome of prenatally detected cardiac malformations. Am J Cardiol 69(17):1471–1474. https://doi.org/10.1016/0002-9149(92)90903-cCrossRefPubMed

22.

Cooper MJ, Enderlein MA, Dyson DC, Rogé CL, Tarnoff H (1995) Fetal echocardiography: retrospective review of clinical experience and an evaluation of indications. Obstet Gynecol 86(4 Pt 1):577–582. https://doi.org/10.1016/0029-7844(95)00215-dCrossRefPubMed

23.

Friedberg MK, Silverman NH (2004) Changing indications for fetal echocardiography in a University Center population. Prenat Diagn 24(10):781–786. https://doi.org/10.1002/pd.981CrossRefPubMed

24.

Komisar J, Srivastava S, Geiger M, Doucette J, Ko H, Shenoy J, Shenoy R (2017) Impact of changing indications and increased utilization of fetal echocardiography on prenatal detection of congenital heart disease. Congenit Heart Dis 12(1):67–73. https://doi.org/10.1111/chd.12405CrossRefPubMed

25.

Boehme C, Fruitman D, Eckersley L, Low R, Bennett J, McBrien A, Alvarez S, Pastuck M, Hornberger LK (2022) The diagnostic yield of fetal echocardiography indications in the current era. J Am Soc Echocardiogr 35(2):217–227.e1. https://doi.org/10.1016/j.echo.2021.09.005CrossRefPubMed

26.

Kim ST, Song J, Huh J, Kang IS, Yang JH, Jun TG, Oh SY, Choi SJ, Roh CR (2019) The effect of multidisciplinary approach on the birth rate of fetuses with prenatally diagnosed congenital heart disease. J Korean Med Sci 34(24):e170. https://doi.org/10.3346/jkms.2019.34.e170CrossRefPubMedPubMedCentral

27.

Donofrio MT, Levy RJ, Schuette JJ, Skurow-Todd K, Sten MB, Stallings C, Pike JI, Krishnan A, Ratnayaka K, Sinha P et al (2013) Specialized delivery room planning for fetuses with critical congenital heart disease. Am J Cardiol 111(5):737–747. https://doi.org/10.1016/j.amjcard.2012.11.029CrossRefPubMed

28.

Boachie MK, Põlajeva T, Frimpong AO (2020) Infant mortality in low- and middle-income countries: does government health spending matter? J Dev Policy Pract 5(1):54–73. https://doi.org/10.1177/2455133320909916CrossRef

29.

Zimmerman M, Sable C (2020) Congenital heart disease in low-and-middle-income countries: focus on sub-Saharan Africa. Am J Med Genet C Semin Med Genet 184(1):36–46. https://doi.org/10.1002/ajmg.c.31769CrossRefPubMed

30.

Jaspers L, Colpani V, Chaker L, van der Lee SJ, Muka T, Imo D, Mendis S, Chowdhury R, Bramer WM, Falla A et al (2015) The global impact of non-communicable diseases on households and impoverishment: a systematic review. Eur J Epidemiol 30(3):163–188. https://doi.org/10.1007/s10654-014-9983-3CrossRefPubMed

31.

Okoror C, Enabudoso E (2023) Establishing fetal cardiac anomalies diagnosis services in low- and middle-income countries (LMICs). Afr J Fetomatern Med 2(1):4–11

32.

Kim ET, Singh K, Moran A, Armbruster D, Kozuki N (2018) Obstetric ultrasound use in low and middle income countries: a narrative review. Reprod Health 15(1):129. https://doi.org/10.1186/s12978-018-0571-yCrossRefPubMedPubMedCentral

33.

Groen RS, Leow JJ, Sadasivam V, Kushner AL (2011) Review: indications for ultrasound use in low- and middle-income countries. Trop Med Int Health 16(12):1525–1535. https://doi.org/10.1111/j.1365-3156.2011.02868.xCrossRefPubMed

34.

Ginsburg AS, Liddy Z, Khazaneh PT, May S, Pervaiz F (2023) A survey of barriers and facilitators to ultrasound use in low- and middle-income countries. Sci Rep 13(1):3322. https://doi.org/10.1038/s41598-023-30454-wCrossRefPubMedPubMedCentral

35.

Rakha S (2020) Awareness assessment for parents of children with congenital heart diseases regarding fetal echocardiography. Turk J Pediatr 62(4):569–577. https://doi.org/10.24953/turkjped.2020.04.006CrossRefPubMed

36.

Warrier D, Saraf R, Maheshwari S, Suresh P, Shah S (2012) Awareness of fetal echo in Indian scenario. Ann Pediatr Cardiol 5(2):156–159CrossRefPubMedPubMedCentral

37.

Kanwal A, Sheikh AM, Saher T (2018) Determining the factors causing delayed referral for fetal echocardiography at a tertiary care hospital. J Saudi Heart Assoc 30(3):205–210. https://doi.org/10.1016/j.jsha.2017.12.001CrossRefPubMed

38.

Akinmoladun JA, Anumba DOC (2019) Fetal imaging and diagnosis services in developing countries—a call to action. Trop J Obstet Gynaecol 36(1):1. https://doi.org/10.4103/TJOG.TJOG_59_18CrossRef

39.

Seyi-Olajide JO, Ma X, Guadagno E, Ademuyiwa A, Poenaru D (2023) Screening methods for congenital anomalies in low and lower-middle income countries: a systematic review. J Pediatr Surg 58(5):986–993. https://doi.org/10.1016/j.jpedsurg.2023.01.038CrossRefPubMed

40.

Majeed A, Jenkins K, Gauvreau K, Forero JF, Pérez Juárez F, Kulkarni S et al (2023) Screening and diagnostic imaging at centres performing congenital heart surgery in middle-income countries. Cardiol Young 33(5):780–786. https://doi.org/10.1017/S1047951122001731CrossRefPubMed

41.

Rakha S, Elmarsafawy H (2021) Nonimmune hydrops fetalis management from the perspective of fetal cardiologists: a single tertiary center experience from Egypt. J Neonatal Perinatal Med 14(2):237–244. https://doi.org/10.3233/NPM-200491CrossRefPubMed

42.

Rychik J, Donaghue DD, Levy S, Fajardo C, Combs J, Zhang X, Szwast A, Diamond GS (2013) Maternal psychological stress after prenatal diagnosis of congenital heart disease. J Pediatr 162(2):302–307.e1. https://doi.org/10.1016/j.jpeds.2012.07.023CrossRefPubMed

43.

Harris KW, Brelsford KM, Kavanaugh-McHugh A, Clayton EW (2020) Uncertainty of prenatally diagnosed congenital heart disease: a qualitative study. JAMA Netw Open 3(5):e204082. https://doi.org/10.1001/jamanetworkopen.2020.4082CrossRefPubMedPubMedCentral

44.

Erbas GS, Herrmann-Lingen C, Ostermayer E, Kovacevic A, Oberhoffer-Fritz R, Ewert P, Wacker-Gussmann A (2023) Anxiety and depression levels in parents after counselling for fetal heart disease. J Clin Med 12(1):394. https://doi.org/10.3390/jcm12010394CrossRefPubMedPubMedCentral

45.

Arya B, Glickstein JS, Levasseur SM, Williams IA (2013) Parents of children with congenital heart disease prefer more information than cardiologists provide. Congenit Heart Dis 8(1):78–85. https://doi.org/10.1111/j.1747-0803.2012.00706.xCrossRefPubMed

46.

Kovacevic A, Elsässer M, Fluhr H, Müller A, Starystach S, Bär S, Gorenflo M (2021) Counseling for fetal heart disease-current standards and best practice. Transl Pediatr 10(8):2225–2234. https://doi.org/10.21037/tp-20-181CrossRefPubMedPubMedCentral

47.

Kovacevic A, Wacker-Gussmann A, Bär S, Elsässer M, Mohammadi Motlagh A, Ostermayer E, Oberhoffer-Fritz R, Ewert P, Gorenflo M, Starystach S (2022) Parents’ perspectives on counseling for fetal heart disease: what matters most? J Clin Med 11(1):278. https://doi.org/10.3390/jcm11010278CrossRefPubMedPubMedCentral

48.

Bratt EL, Järvholm S, Ekman-Joelsson BM, Mattson LÅ, Mellander M (2015) Parent’s experiences of counselling and their need for support following a prenatal diagnosis of congenital heart disease—a qualitative study in a Swedish context. BMC Pregnancy Childbirth 15:171. https://doi.org/10.1186/s12884-015-0610-4CrossRefPubMedPubMedCentral

49.

Pinto NM, Nelson R, Puchalski M, Metz TD, Smith KJ (2014) Cost-effectiveness of prenatal screening strategies for congenital heart disease. Ultrasound Obstet Gynecol 44(1):50–57. https://doi.org/10.1002/uog.13287CrossRefPubMedPubMedCentral

50.

Liang YJ, Fang JX, Sun YX, Feng ZC, Liu CS, Zhang XH et al (2022) The implications of an integrated management model of prenatal diagnosis/postnatal treatment for premature infants with critical congenital heart disease—a case-control study. Cardiovasc Diagn Ther 12(6):868–879. https://doi.org/10.21037/cdt-22-74CrossRefPubMedPubMedCentral

51.

Satou GM, Rheuban K, Alverson D, Lewin M, Mahnke C, Marcin J, Martin GR, Mazur LS, Sahn DJ, Shah S et al (2017) Telemedicine in pediatric cardiology: a scientific statement from the American Heart Association. Circulation 135(11):e648–e678. https://doi.org/10.1161/CIR.0000000000000478CrossRefPubMed

52.

Bolin EH, Collins RT 2nd, Best TH, Zakaria D, Lang SM, Boushka MG, Renno MS, Heil LL, Lowery CL, Bornemeier RA (2020) Implementation of a statewide, multisite fetal tele-echocardiography program: evaluation of more than 1100 fetuses over 9 years. J Perinatol 40(10):1524–1530. https://doi.org/10.1038/s41372-020-0677-2CrossRefPubMed

53.

Fernandes BA, Alves B, Matosinhos AC, Calácio E Silva BL, Dias R, Hasparyk UG, Damásio J, Bastos FM, Simõ E Sesilva AC (2023) The use and role of telemedicine in maternal fetal medicine around the world: an up-to-date. Health Technol (Berl) 13(3):365–372. https://doi.org/10.1007/s12553-023-00742-6CrossRefPubMed

54.

Reis FJJ, Fernandes LG, Saragiotto BT (2021) Telehealth in low- and middle-income countries: bridging the gap or exposing health disparities? Health Policy Technol 10(4):100577. https://doi.org/10.1016/j.hlpt.2021.100577CrossRefPubMedPubMedCentral

55.

Rusingiza E, Alizadeh F, Wolbrink T, Mutamba B, Vinci S, Profita EL, Rulisa S, DelSignore L, Solis J, Geggel R et al (2022) An e-learning pediatric cardiology curriculum for pediatric postgraduate trainees in Rwanda: implementation and evaluation. BMC Med Educ 22(1):179. https://doi.org/10.1186/s12909-022-03222-zCrossRefPubMedPubMedCentral

56.

Maheshwari S, Zheleva B, Rajasekhar V, Batra B (2015) e-Teaching in pediatric cardiology: a paradigm shift. Ann Pediatr Cardiol 8(1):10–13. https://doi.org/10.4103/0974-2069.149512CrossRefPubMedPubMedCentral

57.

van Nisselrooij AEL, Teunissen AKK, Clur SA, Rozendaal L, Pajkrt E, Linskens IH et al (2020) Why are congenital heart defects being missed? Ultrasound Obstet Gynecol 55(6):747–757. https://doi.org/10.1002/uog.20358CrossRefPubMedPubMedCentral

58.

Uzun O, Kennedy J, Davies C, Goodwin A, Thomas N, Rich D et al (2018) Training: improving antenatal detection and outcomes of congenital heart disease. BMJ Open Qual 7(4):e000276. https://doi.org/10.1136/bmjoq-2017-000276CrossRefPubMedPubMedCentral

59.

Cody F, Franklin O, Mc Cay N, Molphy Z, Dicker P, Breathnach FM (2024) Critical congenital heart disease: contemporary prenatal screening performance and outcomes in a multi-centre perinatology service. BMC Pregnancy Childbirth 24(1):163. https://doi.org/10.1186/s12884-024-06350-0CrossRefPubMedPubMedCentral

60.

Hildebrand E, Abrandt Dahlgren M, Sved C, Gottvall T, Blomberg M, Janerot-Sjoberg B (2014) Impact of a standardized training program on midwives’ ability to assess fetal heart anatomy by ultrasound. BMC Med Imaging 14:20. https://doi.org/10.1186/1471-2342-14-20CrossRefPubMedPubMedCentral

61.

Hartmann TJ, Friebe-Hoffmann U, de Gregorio N, de Gregorio A, Lato C, Hüner B, Friedel T, Janni W, Lato K (2022) Novel and flexible ultrasound simulation with smartphones and tablets in fetal echocardiography. Arch Gynecol Obstet 305(1):19–29. https://doi.org/10.1007/s00404-021-06102-xCrossRefPubMed

62.

Janzing P, Nourkami-Tutdibi N, Tutdibi E, Freundt P, von Ostrowski T, Langer M, Zemlin M, Steinhard J (2023) Controlled prospective study on ultrasound simulation training in fetal echocardiography: FESIM II. Arch Gynecol Obstet. https://doi.org/10.1007/s00404-023-07133-2CrossRefPubMed

63.

Ross S, Verstappen A (2023) The role of congenital heart disease patient organizations in advocacy, resources, and support across the lifespan. CJC Pediatr Congenit Heart Dis 2(6):256–266. https://doi.org/10.1016/j.cjcpc.2023.08.006CrossRefPubMedPubMedCentral

Title: Initiating a Fetal Cardiac Program from Scratch in Low- and Middle-Income Countries: Structure, Challenges, and Hopes for Solutions
Author: Shaimaa Rakha
Publication date: 19-04-2024
Publisher: Springer US
Keywords: Echocardiography
Echocardiography
Published in: Pediatric Cardiology
Print ISSN: 0172-0643
Electronic ISSN: 1432-1971
DOI: https://doi.org/10.1007/s00246-024-03479-9

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