Providers and Pregnant Women Perspective on Obstetric Point-Of-Care Ultrasound Use in Peri-Urban Karachi, Pakistan: A Qualitative Study

Providers and Pregnant Women Perspective on Obstetric Point-Of-Care Ultrasound Use in Peri-Urban Karachi, Pakistan: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Providers and Pregnant Women Perspective on Obstetric Point-Of-Care Ultrasound Use in Peri-Urban Karachi, Pakistan: A Qualitative Study Laeba Hussain, Nida Salman Yazdani, Ayesha Khalid, Fariya Ahmed, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9544997/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Ultrasound is essential for antenatal care (ANC), yet access remains limited in many low- and middle-income countries (LMICs) due to shortages of equipment and trained personnel. Point-of-care ultrasound (POCUS) offers a feasible solution for gestational dating, detection of high-risk conditions, and referral decision-making in these settings. Effective integration of POCUS into routine ANC requires understanding both healthcare providers’ (HCPs) and pregnant women’s perspectives as a foundation for trust. Methods A qualitative study was conducted at a peri-urban site in Karachi, Pakistan to explore the perception of obstetric POCUS among HCPs and pregnant women. In-depth interviews (IDIs) were conducted with purposely sampled participants until thematic saturation was achieved, comprising six pregnant women enrolled in an ongoing POCUS cohort study, and three HCPs performing POCUS. Interviews were audio recorded, transcribed, translated, and analyzed using thematic analysis. Results The six common themes identified were role of ultrasound, POCUS experience, benefits of POCUS, limitations and areas of improvement, myths and misconceptions, and recommendations for future use. POCUS was perceived as a valuable and feasible tool for ANC due to its portability and ability to perform rapid assessment closer to communities. Women valued reduced travel times while HCPs highlighted its user-friendly design and short learning curve for basic obstetric assessment and referral decisions. However, concerns regarding technical difficulties and diagnostic limitations were noted. Conclusions Targeted interventions focusing on structured training and community education may support effective integration of POCUS into routine ANC and improve access to obstetric imaging, with potential to improved maternal and neonatal outcomes in underserved communities. point of care ultrasound digital health perceptions pregnant women healthcare providers low- and middle-income countries Background Ultrasound is a safe, non-invasive imaging modality and cornerstone of antenatal care (ANC), enabling accurate estimation of gestational age (GA), monitoring of fetal growth, assessment of placental location and amniotic fluid volume, and early detection of fetal anomalies and maternal complications [ 1 ]. The World Health Organization (WHO) recommends at least one ultrasound scan before 24 weeks of gestation to support positive pregnancy experience [ 2 ]. However, in many low- and middle-income countries (LMICs), access to routine obstetric ultrasound remains out of reach due to shortages of trained sonologists, inadequate equipment, unreliable electricity, and high out-of-pocket costs [ 3 ]. These barriers have accelerated the adoption of point-of-care ultrasound (POCUS) as a practical, portable approach to expanding access to basic obstetric imaging. POCUS refers to focused bedside ultrasound performed with a handheld ultrasound probe by trained health care providers (HCPs) to guide real-time clinical decision making. First introduced nearly three decades ago, POCUS has transformed bedside medicine, and evolved into a core diagnostic tool across multiple specialties worldwide including emergency medicine, internal medicine, anesthesia and obstetrics that can be performed by non-specialist providers with minimum training [ 4 ]. In obstetric practice, POCUS has established itself as a vital tool for estimating GA, determining fetal presentation and viability, and assessing fetal well-being [ 5 ]. A community-based study in the Philippines reported that hand-held ultrasound performed by trained HCPs identified abnormalities in 31.7% of pregnancies and estimated that its use could avert up to 6.3% of maternal and 14.6% of neonatal deaths by enabling timely referral [ 6 ]. Findings from a Kenyan study reported that the use of POCUS in rural clinics improved timely referral for high-risk pregnancies and ensuring continuity of care [ 7 ]. Similarly, in rural Zambia, 21 midwives performed 441 ultrasound scans over six months, with 17% (74 cases) leading to changes in clinical decision-making [ 8 ]. Despite growing evidence of technological feasibility and operational utility, successful integration of POCUS into routine ANC depends on its acceptability and perceived value among both providers and pregnant women. Existing qualitative research has predominantly focused on providers’ experiences, often in rural or facility-based settings, and suggests that nurses and midwives view POCUS as an empowering tool that enhances clinical confidence, improves diagnostic accuracy, and facilitates timely patient referrals [ 9 , 10 ]. In contrast, the perspectives of pregnant women are frequently overlooked, limiting understanding of how misalignment between providers’ and pregnant women’s perspectives could affect trust, uptake of services, and adherence to recommended ANC practices [ 10 ]. Understanding women’s perspectives is also essential for culturally appropriate use, including ensuring privacy during scans, accommodating preferences for provider gender, and addressing community beliefs about ultrasound. By examining providers’ and women’s perspectives simultaneously, this study seeks to identify barriers and facilitators to real-world implementation and to inform strategies that align clinical practice with patient expectations and cultural norms. These insights are expected to inform context-specific strategies for effective integration of POCUS into routine ANC in LMICs. Materials and methods Study Design and Setting: This study used an exploratory qualitative design to understand perception of POCUS among pregnant women and HCPs. The study was conducted between June and September 2025 at the Primary Health Center (PHC) in Brains Colony, a peri-urban community situated along the coastal belt of Bin Qasim Town, Karachi, Pakistan. Bhains Colony, also known as Cattle Colony, is a densely populated neighborhood with an estimated population of approximately 140,000 having undergone rapid urbanization [ 11 ]. Female community health workers (CHWs) conduct quarterly household visits in the colony to document vital events, including pregnancies, delivery outcomes, and deaths while also providing education on ANC, nutrition, and immunizations. In addition, trained community midwives at the PHC provide ANC services and facilitate referrals to public or private health facilities for childbirth. Maternal and newborn health data related to antenatal, delivery, and postnatal care are recorded electronically using a custom-built Android application, ensuring efficient data management and accessibility. Study Participants: This qualitative study comprised two participant groups: pregnant women enrolled in the Fetal Age Machine Learning Initiative (FAMLI) cohort and HCPs. FAMLI is a prospective study that enrolls pregnant women during antenatal care and follows them through delivery. POCUS scans are performed alongside a conventional ultrasound at each visit to support development and validation of GA estimation models and additional obstetric models, including fetal lie, placental location, and amniotic fluid assessment. Pregnant women enrolled in the FAMLI cohort at the Bhains Colony site were approached for participation. Eligible women were aged 15–49 years, able to communicate in Urdu, and had received at least one POCUS scan in the preceding 3 months to ensure better recall of their experiences. Each eligible woman was contacted individually. Those who provided written informed consent were invited for the interview; if a woman declined to consent, the next eligible participant was approached. Recruitment continued until thematic saturation was reached, defined as the point where no new themes or meaningful insights emerged from successive interviews. HCPs who received formal POCUS training, had at least 6 months of experience of performing POCUS scans, and provided written informed consent were eligible for inclusion. As part of the FAMLI cohort, a total of three HCPs were responsible for conducting POCUS scans for the enrolled participants, including two novice users and one expert sonologist. Given this limited and defined pool, all three were approached and consented for participation in the study. Data Collection: Data was collected through in-depth interviews (IDIs). Semi-structured interview guides were developed through an extensive literature search aligned with study objectives (refer to S1 and S2 in Supplement for the guides). The guides included open-ended questions and probes to facilitate in-depth exploration of participants’ experiences. The guides for pregnant women focused on their experience with POCUS, comfort, and trust in information available from the device, cultural and family beliefs, perceived benefits and limitations, and willingness for future use. The guides for HCPs explored themes related to routine antenatal care practices, experience with POCUS, perceived advantages and challenges, patient acceptance, and strategies to enhance its adoption. The IDI guides were forward and back translated into Urdu by two team members who were fluent in both languages. Three pilot interviews with pregnant women were conducted at the study site to assess clarity and relevance; feedback was used to refine wording and add probes to the final guides. Interviews were conducted in Urdu with all participants who provided written informed consent and lasted between 30–45 minutes in a private room at the PHC. To ensure rigor, two researchers who were fluent in the local language were present at the time of each interview, with one conducting the interview and other taking field notes. Recordings were transcribed verbatim in Romanized Urdu and subsequently translated to English. Data saturation was achieved after six IDIs with pregnant women and thematic consistency across the interviews was obtained after three IDIs. All transcripts were reviewed for completeness, anonymity and clarity prior to coding and analysis. This study received approval from The Aga Khan University’s Ethics Review Committee (ERC # 2025-11503-35270). Data Management and Analysis: An inductive approach for thematic analysis was undertaken by the research team using interview transcripts and field notes. The process was guided by Braun and Clarke’s six step framework which included data familiarization, initial code generation, developing and refining themes, evaluating their relevance and reporting the findings [ 12 ]. The research team consisted of multidisciplinary health researchers, all of whom had prior research experience and had attended training workshops in qualitative methods and thematic analysis. Analyses were performed separately for pregnant women and HCPs. Audio recordings of all IDIs conducted in Urdu were first transcribed verbatim in MS Word and then translated into English by authors who are fluent in both languages. Two researchers were present during each IDI and subsequently conducted transcription and translation to maintain contextual accuracy and familiarity with the data. All transcripts were completed and reviewed by the research team to ensure qualitative rigor. Following data familiarization and confirmation that data saturation had been achieved, data was imported into Depose software version 9.2.22 [ 13 ]. Initial open coding was done by three members of the research team using sensitizing concepts derived from the interview guides. As the analysis evolved, codes were constantly compared, merged, and reorganized. Consistency in coding was ensured through regular consensus meetings, where discrepancies were discussed and resolved collaboratively. After thorough cross checking, a final set of codes with relevant data extracts was formulated and was grouped into major themes using MS Excel, aligned with study objectives. Final themes and representative quotations were agreed upon through team discussions and consensus. Results A total of nine participants were included in this qualitative study, comprising six pregnant women and three healthcare providers. The pregnant women were predominantly multiparous and unemployed, with varied educational backgrounds. The healthcare providers represented mixed levels of training and ultrasound expertise, including one expert sonologist and two nonspecialist users. Detailed demographic characteristics are presented in Table 1 . Table 1 Demographic Characteristics of Pregnant Women and the Healthcare Providers Pregnant Women (N = 6) n (%) Age, years; median (range) 29.5 (27–37) Parity; median (range) 3.5 (1–4) Primiparous 1 (16.7) Multiparous 5 (83.3) Education Primary or below 2 (33.3) Secondary 2 (33.3) Higher Secondary or above 2 (33.3) Occupation Unemployed 6 (100) Healthcare Providers (N = 3) n (%) Age, years; median (range) 36 (30–43) Education Higher Secondary or below 1(33.3) Graduate/Postgraduate 2(66.7) Thematic analysis was conducted separately for each participant group and common themes were identified. These included: role of ultrasound, POCUS experience, benefits of POCUS, limitations and areas of improvement, myths and misconceptions regarding ultrasound and recommendations for current and future use. Each participant was assigned a unique identifier to ensure confidentiality. Quotations are presented using participant IDs, where “HCP” denotes healthcare providers (e.g., HCP 01) and “PW” denotes pregnant women (e.g, PW 01). Theme 1: Role of Ultrasound HCPs and Pregnant women shared that ultrasound plays a vital role in confirming pregnancy and accurately determining the gestational age. Pregnant women viewed it as a reliable way to confirm pregnancy, determine gestational age, and monitor the baby’s growth and well-being, which helped them feel reassured throughout their pregnancy. "Ultrasound is important because we can see everything about the baby…how the brain is, how the hands are, how the kidneys are, how the legs are. Basically, it tells you everything." (PW 07) HCPs highlighted its importance in establishing accurate gestational dating, evaluating fetal growth, and enabling early detection of complications which support timely therapeutic decisions and improve outcomes. "The role of ultrasound is that we can see whether the baby is healthy or not. We look at every part of the baby, from head to toe...We also check whether the gestational age matches the baby's growth, if the baby is growing according to the expected timeline." (HCP 03) Theme 2: POCUS Experience Both pregnant women and HCPs reported their experiences with POCUS as positive and emphasized its value for ANC. Many appreciated the quick and convenient nature of the scan. While a few women reported initial anxiety when encountering the device for the first time, most described feeling comfortable once the procedure and its purpose were explained. “I don’t know, it just felt strange… like, what kind of machine is this? Then the lady told me that it’s fine, don’t be worried, nothing will happen…it’s also an ultrasound.” (PW 06) HCPs described POCUS as an efficient and convenient adjunct to routine ultrasound in ANC. Providers emphasized that it allows for immediate bedside assessments of fetal status and could support rapid clinical decision making. "POCUS in my opinion is just like a commercial machine, I don't think there is much difference between POCUS and a commercial ultrasound." (HCP 02) Theme 3: Benefits of POCUS Pregnant women described a range of advantages associated with the use of POCUS in ANC such as its ease of use, and ability to provide rapid results without prolonged waiting. The portable nature of the device reduced the need for travel to health facilities and helped minimize waiting times. "Yes, it’s small, easy to use, gets done quickly…for the big machine…you have to come to the center yourself. But these ladies already come to our homes, and if I tell them that I want an ultrasound, they can bring the machine there as well. That’s the benefit of it." (PW 06) HCPs also appreciated the portability and ease of use of the device. " The ease comes from its simple interface, it’s very user-friendly. That’s what makes it quick and easy for newcomers to learn.” (HCP 02) Another participant described, "If a patient has an emergency, we can quickly go to her home and scan her. We can check for the baby’s heartbeat and movements, to see if the baby is okay or not.” (HCP 03) Theme 4: Limitations of POCUS Despite its advantages, both HCPs and pregnant women acknowledged certain limitations of POCUS that influenced its use in ANC. Pregnant women provided relatively limited reflections on drawbacks, with most views relating to a preference for conventional ultrasound, often shaped by prior experience and the perception that a full, formal scan provides greater diagnostic assurance. "No, this one (points to POCUS) is a different thing, that one is a different thing. The big machine seems better. We’ve always had it done with that (conventional ultrasound)." (PW 06). From the HCPs perspectives, limitations were primarily related to the technical capabilities of POCUS. While it was considered effective for antenatal examinations, HCPs noted that it may be less suitable for detecting complex abnormalities or providing detailed imaging compared with conventional ultrasound. "The difference mainly lies in the resolution. Obviously, the larger commercial machines have much better resolution and more advanced settings for image clarity. In that comparison, POCUS does lag a bit.” (HCP 02) Theme 5: Myths and Misconceptions Regarding Ultrasound Although not directly related to POCUS, pregnant women described myths and misconceptions related to the use of ultrasound during pregnancy, including concerns about potential harm from repeated scans. "They said that getting ultrasounds done repeatedly is discouraged. Like, if we get it done 2–3 times in a month, then the baby is exposed to radiation, and it can cause problems in the eyes and so on." (PW 07) HCPs also shared insights into how POCUS was associated with fear and misconceptions among some women. "Yes, sometimes some patients get scared. They worry that since this is a “different” ultrasound, maybe it could harm them or the baby." (HCP 03) Theme 6: Recommendations for Future Use Pregnant women and HCPs described strong support for the continued use of POCUS in ANC. “Yes, absolutely, I will tell them. I will go and inform my cousins, my cousins are also pregnant right now, also my neighbors, my friends, I’ll go and inform them to come to the center and get the scan with POCUS.” (PW 04) HCPs discussed the adoption of POCUS into routine ANC, reflecting on both facilitators and barriers of its use. "It would really make things easier for patients. If they have difficulty reaching the facility or any kind of obstacle, we could go to their homes and do the scan, that would be excellent." (HCP 01) HCPs also emphasized the importance of educating women and families about the purpose, safety, and benefits of POCUS as means to address misconceptions and build trust within the community. "By holding sessions, big sessions, and going into communities to tell people about it. That way, people will have more information, and it will benefit us a lot too." (HCP 03) The long-term sustainability of POCUS in ANC was dependent on the availability of reliable technical support, and continuous capacity building. "But if you want proper implementation, then actual training programs will have to be organized.” (HCP 02) Discussion This qualitative study explored the perceptions of POCUS among HCPs and pregnant women in a peri-urban community in Karachi. Overall, POCUS was perceived as a feasible and acceptable tool for antenatal care, primarily because of its portability and utility in settings where access to conventional imaging is limited. Participants valued its ability to provide on-site assessment but also identified community and system-level barriers which need to be addressed to ensure broader integration in routine ANC services in LMICs. Overall, the general perception from pregnant women and HCPs regarding POCUS was quite positive. Among pregnant women, satisfaction with POCUS was driven by real-time direct visualization of the fetus during brief scans, which helped build trust in the care received. This finding aligns with previous literature where women described antenatal POCUS as reassuring, valued provider explanations regarding fetal well-being, and expressed willingness to recommend this service to others [ 14 ]. Balmuth et al also observed high patient satisfaction in hospital settings, with patients perceiving shorter scan durations, highlighting how rapid point-of-care imaging may enhance the perceptions of care efficiency [ 15 ]. HCPs also viewed POCUS as beneficial for supporting timely clinical decision-making during ANC. Consistent with evidence from both high-income countries and LMICs, nurses and midwives have reported antenatal POCUS to be useful for assessing key obstetric parameters, including fetal number and presentation, and for guiding referral decisions and maternal counselling [ 16 , 17 ]. Perceived value of POCUS among both groups was intricately linked to convenience and time efficiency, particularly when services are delivered closer to communities. Similar findings have been reported from Kenya where women valued reduced travel and waiting times as well as the potential for lower out-of-pocket expenses, thereby reducing delays in accessing obstetric imaging [ 18 , 19 ]. Qualitative research from rural Nepal reported that trained skilled birth attendants perceived decentralized obstetric ultrasound services and mobile outreach as beneficial for improving access to ANC, enabling earlier identification of high-risk cases, and supporting timely assessments closer to women’s homes [ 20 ]. A mixed-methods study of HCPs from Africa also reported that > 75% of providers believed that POCUS would improve ANC attendance and clinical decision making but needed a strong referral pathway to have a meaningful impact on clinical outcomes [ 21 ]. Taken together, these findings indicate that the acceptability of POCUS is shaped by its ability to ease access barriers for pregnant women, while functioning as an efficient clinical tool for HCPs. Despite its benefits, POCUS uptake is limited by user- and system-level barriers. Evidence from sub–Saharan Africa similarly found that POCUS in ANC was initially viewed as modern and unfamiliar and raised concerns about potential maternal or fetal harm [ 18 , 19 ]. As reflected in our findings, HCPs perceive the limitations of POCUS in obstetrics as primarily technical (e.g., reduced resolution for complex abnormalities) and operational (e.g., ongoing training and technical support needs). Additional studies in similar LMIC contexts have also highlighted challenges such as charging difficulties and unreliable electricity [ 22 , 23 ]. Lower image resolution also shaped expectations around its diagnostic scope. This perception is supported by comparative evidence showing conventional ultrasound machines produce higher image resolution and overall image quality than handheld POCUS devices particularly in obstetric scanning [ 24 ]. Nevertheless, POCUS was valued for its user-friendly design and short learning curve, with portability seen as a key advantage in emergency situations where women may be unable to reach healthcare facilities [ 24 ]. To leverage the advantages offered by POCUS, investments should prioritize building community trust in the tool and implement structured training programs to support task shifting to frontline care providers. Evidence from Kenya demonstrates that large scale training initiatives have expanded the number of rural HCPs able to perform obstetric POCUS, thereby increasing service capacity and coverage for pregnant women [ 25 ]. Synergized efforts for task shifting for POCUS in LMICs has been associated with improved identification of high-risk pregnancies and strengthened referral pathways, ultimately contributing to improved patient outcomes. [ 22 ]. To the best of our knowledge, this study is among the first in Pakistan to explore perceptions of obstetric POCUS from both HCPs and pregnant women, providing a dual perspective on acceptability and feasibility from a LMIC. To avoid any recall bias and account to the low education levels, women who had a recent POCUS and conventional scan were recruited. Despite this strength, study limitations must be acknowledged. The study was conducted in a single peri-urban setting where the parent study was conducted, which may limit its generalizability. In addition, only three HCPs were included, which may not fully capture the range of provider experiences that could emerge during broader implementation of POCUS. Conclusion This study demonstrates that obstetric POCUS is both acceptable and feasible in a peri-urban LMIC setting when integrated within existing antenatal care services. Its portability and ability to provide real-time reassurance may reduce access barriers and support timely referral, particularly where conventional imaging is limited. However, successful scale-up will require structured training, ongoing technical support, community engagement to address misconceptions, and strong referral linkages. With appropriate health system investment, POCUS has the potential to expand equitable access to essential obstetric imaging and strengthen community-level ANC in underserved settings. Abbreviations ANC Antenatal Care LMIC Low and Middle Income Countries POCUS Point-Of-Care Ultrasound HCP Healthcare Provider PW Pregnant Woman GA Gestational Age ICF Informed consent form WHO World Health Organization PHC Primary Health Center CHW Community Health Worker FAMLI Fetal Age Machine Learning Initiative IDI In-Depth Interview Declarations Ethics approval and consent to participate: This study received approval from The Aga Khan University’s Ethics Review Committee (ERC # 2025-11503-35270) and ICF was filled for each participant prior to enrollment. Consent for publication : Participants provided consent for publication. Availability of data and materials: The datasets used during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no competing interest. Funding: The FAMLI study was funded by University of North Carolina through Gates Foundation INV-039969. Authors' contributions: Conceptualization - LH, NY, AK, JS, ZH; Methodology - LH, NY, AK, JS, ZH; Data collection - LH, HJ, FA, IF; Writing (original draft preparation) - LH, FA, HJ; Writing (review and editing) - LH, NY, AK, FJ, IN, KR, BF, JS, ZH; Supervision - ZH. Acknowledgement: The authors would like to thank all participants who agree to provide their time for the interviews. References Huang K, Tao F, Raven J, Liu L, Wu X, Tang S (2012) Utilization of antenatal ultrasound scan and implications for caesarean section: a cross-sectional study in rural Eastern China. BMC Health Serv Res 12:93. 10.1186/1472-6963-12-93 World Health Organization (2022) Imaging ultrasound before 24 weeks of pregnancy: 2022 update to the WHO antenatal care recommendations for a positive pregnancy experience. WHO, Geneva Shah S, Bellows BA, Adedipe AA et al (2015) Perceived barriers in the use of ultrasound in developing countries. Crit Ultrasound J 7:11. 10.1186/s13089-015-0028-2 Fraleigh CD, Duff E (2022) Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment. Nurse Pract 47(8):14–20. 10.1097/01.NPR.0000841944.00536.b2 Recker F, Weber E, Strizek B et al (2021) Point-of-care ultrasound in obstetrics and gynecology. Arch Gynecol Obstet 303(4):871–876. 10.1007/s00404-021-05972-5 Dalmacion GV, Reyles RT, Habana AE et al (2018) Handheld ultrasound to avert maternal and neonatal deaths in 2 regions of the Philippines: an iBuntis intervention study. BMC Pregnancy Childbirth 18:32. 10.1186/s12884-018-1658-8 Wanjiku GW, Bell G, Kapadia S et al (2024) Impact of point-of-care ultrasound use on patient referral decisions in rural Kenya: a mixed methods study. BMC Health Serv Res 24:212. 10.1186/s12913-024-10673-1 Kimberly HH, Murray A, Mennicke M et al (2010) Focused maternal ultrasound by midwives in rural Zambia. Ultrasound Med Biol 36(8):1267–1272. 10.1016/j.ultrasmedbio.2010.05.017 Schoch M, Bennett PN, Currey J et al (2023) Nurses' perceptions of point-of-care ultrasound for haemodialysis access assessment and guided cannulation: a qualitative study. J Clin Nurs 32(23–24):8116–8125. 10.1111/jocn.16877 Onsongo LN, Bett SC, Gachuiri GW et al (2025) Perspectives of health care providers on obstetric point-of-care ultrasound in lower-level health facilities in Kenya. Midwifery. 10.1016/j.midw.2024.104196 Muhammad Zeb MI, Shahid S, Naeem K, Fatima U et al (2022) Profile: maternal and child health surveillance system in Peri-urban areas of Karachi, Pakistan. Gates Open Res 2:2 Cooper HE, Camic PM, Long DL et al (2012) APA handbook of research methods in psychology, vol 2. American Psychological Association, Washington DC Lieber E, Salmona M, Kaczynski D (2021) Introduction to Dedoose for mixed analysis. Routledge reviewer’s guide to mixed methods analysis. Routledge, pp 319–330 Payesa C, Seyama L, Chimwaza Y et al (2025) Feasibility and acceptability of point-of-care ultrasound delivered by midwives during routine antenatal care in Malawi. BMJ Open 15:e100515. 10.1136/bmjopen-2025-100515 Balmuth EA, Luan D, Jannat-Khah D et al (2024) Point-of-care ultrasound (POCUS): Assessing patient satisfaction and socioemotional benefits in hospital setting. PLoS ONE 19:e0298665. 10.1371/journal.pone.0298665 Mubuuke AG, Erem G, Nassanga R et al (2023) Point-of-care obstetric ultrasound training for midwives and nurses in Sub-Saharan Africa: qualitative study. BMC Res Notes 16:287. 10.1186/s13104-023-06569-8 Johnston BK, Darling EK, Malott A et al (2024) Canadian midwives' perspectives on point-of-care ultrasound in obstetrical care. Heliyon 10(6). 10.1016/j.heliyon.2024.e27512 Kumar MB, Mulongo CM, Pincerato L et al (2024) Task sharing for increasing access to obstetric ultrasonography: a formative qualitative study of nurse-led scanning with telemedicine review in Kenya. Oxf Open Digit Health. ;2:oqae037. 2024 Aug 28. 10.1093/oodh/oqae037 Koech A, Musitia PM, Mwashigadi GM et al (2022) Acceptability and feasibility of a low-cost device for gestational age assessment in a low-resource setting. JMIR Hum Factors 9:e34823. 10.2196/34823 Kim C, Wagle K, Shrestha B et al (2023) Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study. BMC Pregnancy Childbirth 23:574. 10.1186/s12884-023-05876-z Della Ripa S, Santos N, Walker D (2025) AI-enabled obstetric point-of-care ultrasound in low- and middle-income countries. BMC Pregnancy Childbirth 25:1–17. 10.1186/s12884-025-07796-6 Abrokwa SK, Ruby LC, Heuvelings CC et al (2022) Task shifting for point-of-care ultrasound in low- and middle-income countries: systematic review. EClinicalMedicine 45:101333. 10.1016/j.eclinm.2022.101333 Bellows B, Totten J, Shah S et al (2015) Perceived barriers in point-of-care ultrasound use in WWAMI region. J Emerg Med Crit Care 1:4 Salimi N, Gonzalez-Fiol A, Yanez ND et al (2022) Ultrasound image quality comparison between handheld and mid-range ultrasound machine. POCUS J 7:154. 10.24908/pocus.v7i1.15052 Githemo G, Wanyoro A, Masika J et al (2025) Evaluation of large-scale implementation of obstetric point-of-care ultrasound in Kenya using RE-AIM framework. BMC Health Serv Res 25:1016. 10.1186/s12913-025-13212-8 Additional Declarations No competing interests reported. Supplementary Files S2IDIguideforHCPs.pdf S1IDIGuideforPregnantWomen.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 06 May, 2026 Editor assigned by journal 30 Apr, 2026 Editor invited by journal 29 Apr, 2026 Submission checks completed at journal 29 Apr, 2026 First submitted to journal 29 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9544997","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":638860931,"identity":"217e910b-bcc9-468e-9511-9203aca64695","order_by":0,"name":"Laeba Hussain","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Laeba","middleName":"","lastName":"Hussain","suffix":""},{"id":638860932,"identity":"a450fa2c-ef78-4323-b549-d3c452e1fd61","order_by":1,"name":"Nida Salman Yazdani","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Nida","middleName":"Salman","lastName":"Yazdani","suffix":""},{"id":638860933,"identity":"90b9a196-6d63-4996-99f1-92569e1ea642","order_by":2,"name":"Ayesha Khalid","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Ayesha","middleName":"","lastName":"Khalid","suffix":""},{"id":638860934,"identity":"d1f8c52c-c3a0-4c40-9c09-ddd938e0bca4","order_by":3,"name":"Fariya Ahmed","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Fariya","middleName":"","lastName":"Ahmed","suffix":""},{"id":638860935,"identity":"6efd6b75-514a-4967-9c57-e14e42f2d55b","order_by":4,"name":"Hamna Javed","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Hamna","middleName":"","lastName":"Javed","suffix":""},{"id":638860936,"identity":"e4dc8897-49a0-4328-a2d3-6db27f956039","order_by":5,"name":"Ishrat Fatima","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Ishrat","middleName":"","lastName":"Fatima","suffix":""},{"id":638860937,"identity":"59f46df2-4916-4bcb-b2c2-84daca38af7e","order_by":6,"name":"Imran Nisar","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Imran","middleName":"","lastName":"Nisar","suffix":""},{"id":638860938,"identity":"fd188264-85cf-460d-a722-bbb07e836a3f","order_by":7,"name":"Fyezah Jehan","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Fyezah","middleName":"","lastName":"Jehan","suffix":""},{"id":638860939,"identity":"61267bd8-c230-4f44-8ee8-0f2b37a612f2","order_by":8,"name":"Katelyn Rittenhouse","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Katelyn","middleName":"","lastName":"Rittenhouse","suffix":""},{"id":638860940,"identity":"456793cf-b352-4565-9477-51bc0df701f9","order_by":9,"name":"Bethany L. Freeman","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Bethany","middleName":"L.","lastName":"Freeman","suffix":""},{"id":638860941,"identity":"322d0d48-d66c-4433-b8d4-ccbf1ee4debe","order_by":10,"name":"Jeffery Stringer","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Jeffery","middleName":"","lastName":"Stringer","suffix":""},{"id":638860942,"identity":"2f32ab7b-db57-4ad2-a77f-46f9104d499a","order_by":11,"name":"Zahra Hoodbhoy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYFACHhBxAIhz2ICEDYMEXJBILWmkazlMWIt8+9ljH34w3JHjZ8899uBj23l5yRkJjA/etuHWwtiTlzyzh+GZsWTPu3TDmW23DWdLJDAbzsWjhZkhxxjojMOJG27kmEnztt1mnCeRwAZk4NbCxv/GmPEPQss5e6AW9t/4tPBI5BgzI9lyIBHoMDZmfFokJN4YM8sYHAb5JU1yxrlkoM8eNkvOOYdbi3x/jjHjm4rD4BCT+FBmZzvjePLBD2/KcGuBAAMozcgGJhsIqUcGf0hRPApGwSgYBSMFAADpRk4FViH9TgAAAABJRU5ErkJggg==","orcid":"","institution":"Aga Khan University","correspondingAuthor":true,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Hoodbhoy","suffix":""}],"badges":[],"createdAt":"2026-04-27 17:53:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9544997/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9544997/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109405450,"identity":"88caff77-2aaa-482f-9947-3a57b7a7da21","added_by":"auto","created_at":"2026-05-17 13:18:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":194425,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9544997/v1/758143c3-a91c-494d-853d-279f4fbbd213.pdf"},{"id":109320917,"identity":"9cffff07-f2e4-42ce-8945-b1f12e14ec85","added_by":"auto","created_at":"2026-05-15 13:35:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":175486,"visible":true,"origin":"","legend":"","description":"","filename":"S2IDIguideforHCPs.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9544997/v1/22d6e5ef2299f78156c22e7b.pdf"},{"id":109320918,"identity":"8576cd52-1ae0-4c48-93b0-ecb90909b443","added_by":"auto","created_at":"2026-05-15 13:35:41","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":186103,"visible":true,"origin":"","legend":"","description":"","filename":"S1IDIGuideforPregnantWomen.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9544997/v1/6a096a5cf0d4cfd6e1535fa9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Providers and Pregnant Women Perspective on Obstetric Point-Of-Care Ultrasound Use in Peri-Urban Karachi, Pakistan: A Qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eUltrasound is a safe, non-invasive imaging modality and cornerstone of antenatal care (ANC), enabling accurate estimation of gestational age (GA), monitoring of fetal growth, assessment of placental location and amniotic fluid volume, and early detection of fetal anomalies and maternal complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The World Health Organization (WHO) recommends at least one ultrasound scan before 24 weeks of gestation to support positive pregnancy experience [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, in many low- and middle-income countries (LMICs), access to routine obstetric ultrasound remains out of reach due to shortages of trained sonologists, inadequate equipment, unreliable electricity, and high out-of-pocket costs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These barriers have accelerated the adoption of point-of-care ultrasound (POCUS) as a practical, portable approach to expanding access to basic obstetric imaging.\u003c/p\u003e \u003cp\u003ePOCUS refers to focused bedside ultrasound performed with a handheld ultrasound probe by trained health care providers (HCPs) to guide real-time clinical decision making. First introduced nearly three decades ago, POCUS has transformed bedside medicine, and evolved into a core diagnostic tool across multiple specialties worldwide including emergency medicine, internal medicine, anesthesia and obstetrics that can be performed by non-specialist providers with minimum training [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In obstetric practice, POCUS has established itself as a vital tool for estimating GA, determining fetal presentation and viability, and assessing fetal well-being [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A community-based study in the Philippines reported that hand-held ultrasound performed by trained HCPs identified abnormalities in 31.7% of pregnancies and estimated that its use could avert up to 6.3% of maternal and 14.6% of neonatal deaths by enabling timely referral [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Findings from a Kenyan study reported that the use of POCUS in rural clinics improved timely referral for high-risk pregnancies and ensuring continuity of care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, in rural Zambia, 21 midwives performed 441 ultrasound scans over six months, with 17% (74 cases) leading to changes in clinical decision-making [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite growing evidence of technological feasibility and operational utility, successful integration of POCUS into routine ANC depends on its acceptability and perceived value among both providers and pregnant women. Existing qualitative research has predominantly focused on providers\u0026rsquo; experiences, often in rural or facility-based settings, and suggests that nurses and midwives view POCUS as an empowering tool that enhances clinical confidence, improves diagnostic accuracy, and facilitates timely patient referrals [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In contrast, the perspectives of pregnant women are frequently overlooked, limiting understanding of how misalignment between providers\u0026rsquo; and pregnant women\u0026rsquo;s perspectives could affect trust, uptake of services, and adherence to recommended ANC practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Understanding women\u0026rsquo;s perspectives is also essential for culturally appropriate use, including ensuring privacy during scans, accommodating preferences for provider gender, and addressing community beliefs about ultrasound. By examining providers\u0026rsquo; and women\u0026rsquo;s perspectives simultaneously, this study seeks to identify barriers and facilitators to real-world implementation and to inform strategies that align clinical practice with patient expectations and cultural norms. These insights are expected to inform context-specific strategies for effective integration of POCUS into routine ANC in LMICs.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting:\u003c/h2\u003e \u003cp\u003eThis study used an exploratory qualitative design to understand perception of POCUS among pregnant women and HCPs. The study was conducted between June and September 2025 at the Primary Health Center (PHC) in Brains Colony, a peri-urban community situated along the coastal belt of Bin Qasim Town, Karachi, Pakistan. Bhains Colony, also known as Cattle Colony, is a densely populated neighborhood with an estimated population of approximately 140,000 having undergone rapid urbanization [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Female community health workers (CHWs) conduct quarterly household visits in the colony to document vital events, including pregnancies, delivery outcomes, and deaths while also providing education on ANC, nutrition, and immunizations. In addition, trained community midwives at the PHC provide ANC services and facilitate referrals to public or private health facilities for childbirth. Maternal and newborn health data related to antenatal, delivery, and postnatal care are recorded electronically using a custom-built Android application, ensuring efficient data management and accessibility.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Participants:\u003c/h3\u003e\n\u003cp\u003eThis qualitative study comprised two participant groups: pregnant women enrolled in the Fetal Age Machine Learning Initiative (FAMLI) cohort and HCPs. FAMLI is a prospective study that enrolls pregnant women during antenatal care and follows them through delivery. POCUS scans are performed alongside a conventional ultrasound at each visit to support development and validation of GA estimation models and additional obstetric models, including fetal lie, placental location, and amniotic fluid assessment.\u003c/p\u003e \u003cp\u003ePregnant women enrolled in the FAMLI cohort at the Bhains Colony site were approached for participation. Eligible women were aged 15\u0026ndash;49 years, able to communicate in Urdu, and had received at least one POCUS scan in the preceding 3 months to ensure better recall of their experiences. Each eligible woman was contacted individually. Those who provided written informed consent were invited for the interview; if a woman declined to consent, the next eligible participant was approached. Recruitment continued until thematic saturation was reached, defined as the point where no new themes or meaningful insights emerged from successive interviews. HCPs who received formal POCUS training, had at least 6 months of experience of performing POCUS scans, and provided written informed consent were eligible for inclusion. As part of the FAMLI cohort, a total of three HCPs were responsible for conducting POCUS scans for the enrolled participants, including two novice users and one expert sonologist. Given this limited and defined pool, all three were approached and consented for participation in the study.\u003c/p\u003e\n\u003ch3\u003eData Collection:\u003c/h3\u003e\n\u003cp\u003eData was collected through in-depth interviews (IDIs). Semi-structured interview guides were developed through an extensive literature search aligned with study objectives (refer to S1 and S2 in Supplement for the guides). The guides included open-ended questions and probes to facilitate in-depth exploration of participants\u0026rsquo; experiences. The guides for pregnant women focused on their experience with POCUS, comfort, and trust in information available from the device, cultural and family beliefs, perceived benefits and limitations, and willingness for future use. The guides for HCPs explored themes related to routine antenatal care practices, experience with POCUS, perceived advantages and challenges, patient acceptance, and strategies to enhance its adoption. The IDI guides were forward and back translated into Urdu by two team members who were fluent in both languages. Three pilot interviews with pregnant women were conducted at the study site to assess clarity and relevance; feedback was used to refine wording and add probes to the final guides. Interviews were conducted in Urdu with all participants who provided written informed consent and lasted between 30\u0026ndash;45 minutes in a private room at the PHC. To ensure rigor, two researchers who were fluent in the local language were present at the time of each interview, with one conducting the interview and other taking field notes. Recordings were transcribed verbatim in Romanized Urdu and subsequently translated to English. Data saturation was achieved after six IDIs with pregnant women and thematic consistency across the interviews was obtained after three IDIs. All transcripts were reviewed for completeness, anonymity and clarity prior to coding and analysis. This study received approval from The Aga Khan University\u0026rsquo;s Ethics Review Committee (ERC # 2025-11503-35270).\u003c/p\u003e\n\u003ch3\u003eData Management and Analysis:\u003c/h3\u003e\n\u003cp\u003eAn inductive approach for thematic analysis was undertaken by the research team using interview transcripts and field notes. The process was guided by Braun and Clarke\u0026rsquo;s six step framework which included data familiarization, initial code generation, developing and refining themes, evaluating their relevance and reporting the findings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The research team consisted of multidisciplinary health researchers, all of whom had prior research experience and had attended training workshops in qualitative methods and thematic analysis. Analyses were performed separately for pregnant women and HCPs. Audio recordings of all IDIs conducted in Urdu were first transcribed verbatim in MS Word and then translated into English by authors who are fluent in both languages. Two researchers were present during each IDI and subsequently conducted transcription and translation to maintain contextual accuracy and familiarity with the data. All transcripts were completed and reviewed by the research team to ensure qualitative rigor. Following data familiarization and confirmation that data saturation had been achieved, data was imported into Depose software version 9.2.22 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Initial open coding was done by three members of the research team using sensitizing concepts derived from the interview guides. As the analysis evolved, codes were constantly compared, merged, and reorganized. Consistency in coding was ensured through regular consensus meetings, where discrepancies were discussed and resolved collaboratively. After thorough cross checking, a final set of codes with relevant data extracts was formulated and was grouped into major themes using MS Excel, aligned with study objectives. Final themes and representative quotations were agreed upon through team discussions and consensus.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of nine participants were included in this qualitative study, comprising six pregnant women and three healthcare providers. The pregnant women were predominantly multiparous and unemployed, with varied educational backgrounds. The healthcare providers represented mixed levels of training and ultrasound expertise, including one expert sonologist and two nonspecialist users. Detailed demographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Pregnant Women and the Healthcare Providers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnant Women (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years; median (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.5 (27\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity; median (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Secondary or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealthcare Providers (N\u0026thinsp;=\u0026thinsp;3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years; median (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (30\u0026ndash;43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Secondary or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate/Postgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThematic analysis was conducted separately for each participant group and common themes were identified. These included: role of ultrasound, POCUS experience, benefits of POCUS, limitations and areas of improvement, myths and misconceptions regarding ultrasound and recommendations for current and future use. Each participant was assigned a unique identifier to ensure confidentiality. Quotations are presented using participant IDs, where \u0026ldquo;HCP\u0026rdquo; denotes healthcare providers (e.g., HCP 01) and \u0026ldquo;PW\u0026rdquo; denotes pregnant women (e.g, PW 01).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Role of Ultrasound\u003c/h2\u003e \u003cp\u003eHCPs and Pregnant women shared that ultrasound plays a vital role in confirming pregnancy and accurately determining the gestational age. Pregnant women viewed it as a reliable way to confirm pregnancy, determine gestational age, and monitor the baby\u0026rsquo;s growth and well-being, which helped them feel reassured throughout their pregnancy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Ultrasound is important because we can see everything about the baby\u0026hellip;how the brain is, how the hands are, how the kidneys are, how the legs are. Basically, it tells you everything.\" (PW 07)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHCPs highlighted its importance in establishing accurate gestational dating, evaluating fetal growth, and enabling early detection of complications which support timely therapeutic decisions and improve outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The role of ultrasound is that we can see whether the baby is healthy or not. We look at every part of the baby, from head to toe...We also check whether the gestational age matches the baby's growth, if the baby is growing according to the expected timeline.\" (HCP 03)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 2: POCUS Experience\u003c/h3\u003e\n\u003cp\u003eBoth pregnant women and HCPs reported their experiences with POCUS as positive and emphasized its value for ANC. Many appreciated the quick and convenient nature of the scan. While a few women reported initial anxiety when encountering the device for the first time, most described feeling comfortable once the procedure and its purpose were explained.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know, it just felt strange\u0026hellip; like, what kind of machine is this? Then the lady told me that it\u0026rsquo;s fine, don\u0026rsquo;t be worried, nothing will happen\u0026hellip;it\u0026rsquo;s also an ultrasound.\u0026rdquo; (PW 06)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHCPs described POCUS as an efficient and convenient adjunct to routine ultrasound in ANC. Providers emphasized that it allows for immediate bedside assessments of fetal status and could support rapid clinical decision making.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"POCUS in my opinion is just like a commercial machine, I don't think there is much difference between POCUS and a commercial ultrasound.\" (HCP 02)\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eTheme 3: Benefits of POCUS\u003c/h3\u003e\n\u003cp\u003ePregnant women described a range of advantages associated with the use of POCUS in ANC such as its ease of use, and ability to provide rapid results without prolonged waiting. The portable nature of the device reduced the need for travel to health facilities and helped minimize waiting times.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Yes, it\u0026rsquo;s small, easy to use, gets done quickly\u0026hellip;for the big machine\u0026hellip;you have to come to the center yourself. But these ladies already come to our homes, and if I tell them that I want an ultrasound, they can bring the machine there as well. That\u0026rsquo;s the benefit of it.\" (PW 06)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHCPs also appreciated the portability and ease of use of the device.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\" The ease comes from its simple interface, it\u0026rsquo;s very user-friendly. That\u0026rsquo;s what makes it quick and easy for newcomers to learn.\u0026rdquo; (HCP 02)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother participant described,\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"If a patient has an emergency, we can quickly go to her home and scan her. We can check for the baby\u0026rsquo;s heartbeat and movements, to see if the baby is okay or not.\u0026rdquo; (HCP 03)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Limitations of POCUS\u003c/h2\u003e \u003cp\u003eDespite its advantages, both HCPs and pregnant women acknowledged certain limitations of POCUS that influenced its use in ANC. Pregnant women provided relatively limited reflections on drawbacks, with most views relating to a preference for conventional ultrasound, often shaped by prior experience and the perception that a full, formal scan provides greater diagnostic assurance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"No, this one (points to POCUS) is a different thing, that one is a different thing. The big machine seems better. We\u0026rsquo;ve always had it done with that (conventional ultrasound).\" (PW 06).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFrom the HCPs perspectives, limitations were primarily related to the technical capabilities of POCUS. While it was considered effective for antenatal examinations, HCPs noted that it may be less suitable for detecting complex abnormalities or providing detailed imaging compared with conventional ultrasound.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The difference mainly lies in the resolution. Obviously, the larger commercial machines have much better resolution and more advanced settings for image clarity. In that comparison, POCUS does lag a bit.\u0026rdquo; (HCP 02)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Myths and Misconceptions Regarding Ultrasound\u003c/h2\u003e \u003cp\u003eAlthough not directly related to POCUS, pregnant women described myths and misconceptions related to the use of ultrasound during pregnancy, including concerns about potential harm from repeated scans.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"They said that getting ultrasounds done repeatedly is discouraged. Like, if we get it done 2\u0026ndash;3 times in a month, then the baby is exposed to radiation, and it can cause problems in the eyes and so on.\" (PW 07)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHCPs also shared insights into how POCUS was associated with fear and misconceptions among some women.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Yes, sometimes some patients get scared. They worry that since this is a \u0026ldquo;different\u0026rdquo; ultrasound, maybe it could harm them or the baby.\" (HCP 03)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 6: Recommendations for Future Use\u003c/h2\u003e \u003cp\u003ePregnant women and HCPs described strong support for the continued use of POCUS in ANC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, absolutely, I will tell them. I will go and inform my cousins, my cousins are also pregnant right now, also my neighbors, my friends, I\u0026rsquo;ll go and inform them to come to the center and get the scan with POCUS.\u0026rdquo; (PW 04)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHCPs discussed the adoption of POCUS into routine ANC, reflecting on both facilitators and barriers of its use.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It would really make things easier for patients. If they have difficulty reaching the facility or any kind of obstacle, we could go to their homes and do the scan, that would be excellent.\" (HCP 01)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHCPs also emphasized the importance of educating women and families about the purpose, safety, and benefits of POCUS as means to address misconceptions and build trust within the community.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"By holding sessions, big sessions, and going into communities to tell people about it. That way, people will have more information, and it will benefit us a lot too.\" (HCP 03)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe long-term sustainability of POCUS in ANC was dependent on the availability of reliable technical support, and continuous capacity building.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"But if you want proper implementation, then actual training programs will have to be organized.\u0026rdquo; (HCP 02)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study explored the perceptions of POCUS among HCPs and pregnant women in a peri-urban community in Karachi. Overall, POCUS was perceived as a feasible and acceptable tool for antenatal care, primarily because of its portability and utility in settings where access to conventional imaging is limited. Participants valued its ability to provide on-site assessment but also identified community and system-level barriers which need to be addressed to ensure broader integration in routine ANC services in LMICs.\u003c/p\u003e \u003cp\u003eOverall, the general perception from pregnant women and HCPs regarding POCUS was quite positive. Among pregnant women, satisfaction with POCUS was driven by real-time direct visualization of the fetus during brief scans, which helped build trust in the care received. This finding aligns with previous literature where women described antenatal POCUS as reassuring, valued provider explanations regarding fetal well-being, and expressed willingness to recommend this service to others [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Balmuth et al also observed high patient satisfaction in hospital settings, with patients perceiving shorter scan durations, highlighting how rapid point-of-care imaging may enhance the perceptions of care efficiency [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. HCPs also viewed POCUS as beneficial for supporting timely clinical decision-making during ANC. Consistent with evidence from both high-income countries and LMICs, nurses and midwives have reported antenatal POCUS to be useful for assessing key obstetric parameters, including fetal number and presentation, and for guiding referral decisions and maternal counselling [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePerceived value of POCUS among both groups was intricately linked to convenience and time efficiency, particularly when services are delivered closer to communities. Similar findings have been reported from Kenya where women valued reduced travel and waiting times as well as the potential for lower out-of-pocket expenses, thereby reducing delays in accessing obstetric imaging [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Qualitative research from rural Nepal reported that trained skilled birth attendants perceived decentralized obstetric ultrasound services and mobile outreach as beneficial for improving access to ANC, enabling earlier identification of high-risk cases, and supporting timely assessments closer to women\u0026rsquo;s homes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A mixed-methods study of HCPs from Africa also reported that \u0026gt;\u0026thinsp;75% of providers believed that POCUS would improve ANC attendance and clinical decision making but needed a strong referral pathway to have a meaningful impact on clinical outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Taken together, these findings indicate that the acceptability of POCUS is shaped by its ability to ease access barriers for pregnant women, while functioning as an efficient clinical tool for HCPs.\u003c/p\u003e \u003cp\u003eDespite its benefits, POCUS uptake is limited by user- and system-level barriers. Evidence from sub\u0026ndash;Saharan Africa similarly found that POCUS in ANC was initially viewed as modern and unfamiliar and raised concerns about potential maternal or fetal harm [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As reflected in our findings, HCPs perceive the limitations of POCUS in obstetrics as primarily technical (e.g., reduced resolution for complex abnormalities) and operational (e.g., ongoing training and technical support needs). Additional studies in similar LMIC contexts have also highlighted challenges such as charging difficulties and unreliable electricity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Lower image resolution also shaped expectations around its diagnostic scope. This perception is supported by comparative evidence showing conventional ultrasound machines produce higher image resolution and overall image quality than handheld POCUS devices particularly in obstetric scanning [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nevertheless, POCUS was valued for its user-friendly design and short learning curve, with portability seen as a key advantage in emergency situations where women may be unable to reach healthcare facilities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo leverage the advantages offered by POCUS, investments should prioritize building community trust in the tool and implement structured training programs to support task shifting to frontline care providers. Evidence from Kenya demonstrates that large scale training initiatives have expanded the number of rural HCPs able to perform obstetric POCUS, thereby increasing service capacity and coverage for pregnant women [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Synergized efforts for task shifting for POCUS in LMICs has been associated with improved identification of high-risk pregnancies and strengthened referral pathways, ultimately contributing to improved patient outcomes. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this study is among the first in Pakistan to explore perceptions of obstetric POCUS from both HCPs and pregnant women, providing a dual perspective on acceptability and feasibility from a LMIC. To avoid any recall bias and account to the low education levels, women who had a recent POCUS and conventional scan were recruited. Despite this strength, study limitations must be acknowledged. The study was conducted in a single peri-urban setting where the parent study was conducted, which may limit its generalizability. In addition, only three HCPs were included, which may not fully capture the range of provider experiences that could emerge during broader implementation of POCUS.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that obstetric POCUS is both acceptable and feasible in a peri-urban LMIC setting when integrated within existing antenatal care services. Its portability and ability to provide real-time reassurance may reduce access barriers and support timely referral, particularly where conventional imaging is limited. However, successful scale-up will require structured training, ongoing technical support, community engagement to address misconceptions, and strong referral linkages. With appropriate health system investment, POCUS has the potential to expand equitable access to essential obstetric imaging and strengthen community-level ANC in underserved settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntenatal Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow and Middle Income Countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOCUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePoint-Of-Care Ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare Provider\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePregnant Woman\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGestational Age\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInformed consent form\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Center\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFAMLI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFetal Age Machine Learning Initiative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-Depth Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study received approval from The Aga Khan University’s Ethics Review Committee (ERC # 2025-11503-35270) and ICF was filled for each participant prior to enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Participants provided consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The FAMLI study was funded by University of North Carolina through Gates Foundation INV-039969.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e Conceptualization - LH, NY, AK, JS, ZH; Methodology - LH, NY, AK, JS, ZH; Data collection - LH, HJ, FA, IF; Writing (original draft preparation) - LH, FA, HJ; Writing (review and editing) - LH, NY, AK, FJ, IN, KR, BF, JS, ZH; Supervision - ZH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e The authors would like to thank all participants who agree to provide their time for the interviews.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHuang K, Tao F, Raven J, Liu L, Wu X, Tang S (2012) Utilization of antenatal ultrasound scan and implications for caesarean section: a cross-sectional study in rural Eastern China. BMC Health Serv Res 12:93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1472-6963-12-93\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-12-93\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2022) Imaging ultrasound before 24 weeks of pregnancy: 2022 update to the WHO antenatal care recommendations for a positive pregnancy experience. WHO, Geneva\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah S, Bellows BA, Adedipe AA et al (2015) Perceived barriers in the use of ultrasound in developing countries. Crit Ultrasound J 7:11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13089-015-0028-2\u003c/span\u003e\u003cspan address=\"10.1186/s13089-015-0028-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFraleigh CD, Duff E (2022) Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment. Nurse Pract 47(8):14\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.NPR.0000841944.00536.b2\u003c/span\u003e\u003cspan address=\"10.1097/01.NPR.0000841944.00536.b2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRecker F, Weber E, Strizek B et al (2021) Point-of-care ultrasound in obstetrics and gynecology. Arch Gynecol Obstet 303(4):871\u0026ndash;876. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00404-021-05972-5\u003c/span\u003e\u003cspan address=\"10.1007/s00404-021-05972-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDalmacion GV, Reyles RT, Habana AE et al (2018) Handheld ultrasound to avert maternal and neonatal deaths in 2 regions of the Philippines: an iBuntis intervention study. BMC Pregnancy Childbirth 18:32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-018-1658-8\u003c/span\u003e\u003cspan address=\"10.1186/s12884-018-1658-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWanjiku GW, Bell G, Kapadia S et al (2024) Impact of point-of-care ultrasound use on patient referral decisions in rural Kenya: a mixed methods study. BMC Health Serv Res 24:212. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-024-10673-1\u003c/span\u003e\u003cspan address=\"10.1186/s12913-024-10673-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKimberly HH, Murray A, Mennicke M et al (2010) Focused maternal ultrasound by midwives in rural Zambia. Ultrasound Med Biol 36(8):1267\u0026ndash;1272. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ultrasmedbio.2010.05.017\u003c/span\u003e\u003cspan address=\"10.1016/j.ultrasmedbio.2010.05.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoch M, Bennett PN, Currey J et al (2023) Nurses' perceptions of point-of-care ultrasound for haemodialysis access assessment and guided cannulation: a qualitative study. J Clin Nurs 32(23\u0026ndash;24):8116\u0026ndash;8125. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jocn.16877\u003c/span\u003e\u003cspan address=\"10.1111/jocn.16877\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnsongo LN, Bett SC, Gachuiri GW et al (2025) Perspectives of health care providers on obstetric point-of-care ultrasound in lower-level health facilities in Kenya. Midwifery. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.midw.2024.104196\u003c/span\u003e\u003cspan address=\"10.1016/j.midw.2024.104196\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammad Zeb MI, Shahid S, Naeem K, Fatima U et al (2022) Profile: maternal and child health surveillance system in Peri-urban areas of Karachi, Pakistan. Gates Open Res 2:2\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper HE, Camic PM, Long DL et al (2012) APA handbook of research methods in psychology, vol 2. American Psychological Association, Washington DC\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLieber E, Salmona M, Kaczynski D (2021) Introduction to Dedoose for mixed analysis. Routledge reviewer\u0026rsquo;s guide to mixed methods analysis. Routledge, pp 319\u0026ndash;330\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePayesa C, Seyama L, Chimwaza Y et al (2025) Feasibility and acceptability of point-of-care ultrasound delivered by midwives during routine antenatal care in Malawi. BMJ Open 15:e100515. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2025-100515\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2025-100515\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalmuth EA, Luan D, Jannat-Khah D et al (2024) Point-of-care ultrasound (POCUS): Assessing patient satisfaction and socioemotional benefits in hospital setting. PLoS ONE 19:e0298665. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0298665\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0298665\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMubuuke AG, Erem G, Nassanga R et al (2023) Point-of-care obstetric ultrasound training for midwives and nurses in Sub-Saharan Africa: qualitative study. BMC Res Notes 16:287. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13104-023-06569-8\u003c/span\u003e\u003cspan address=\"10.1186/s13104-023-06569-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnston BK, Darling EK, Malott A et al (2024) Canadian midwives' perspectives on point-of-care ultrasound in obstetrical care. Heliyon 10(6). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.heliyon.2024.e27512\u003c/span\u003e\u003cspan address=\"10.1016/j.heliyon.2024.e27512\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar MB, Mulongo CM, Pincerato L et al (2024) Task sharing for increasing access to obstetric ultrasonography: a formative qualitative study of nurse-led scanning with telemedicine review in Kenya. Oxf Open Digit Health. ;2:oqae037. 2024 Aug 28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/oodh/oqae037\u003c/span\u003e\u003cspan address=\"10.1093/oodh/oqae037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoech A, Musitia PM, Mwashigadi GM et al (2022) Acceptability and feasibility of a low-cost device for gestational age assessment in a low-resource setting. JMIR Hum Factors 9:e34823. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2196/34823\u003c/span\u003e\u003cspan address=\"10.2196/34823\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim C, Wagle K, Shrestha B et al (2023) Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study. BMC Pregnancy Childbirth 23:574. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-023-05876-z\u003c/span\u003e\u003cspan address=\"10.1186/s12884-023-05876-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDella Ripa S, Santos N, Walker D (2025) AI-enabled obstetric point-of-care ultrasound in low- and middle-income countries. BMC Pregnancy Childbirth 25:1\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-025-07796-6\u003c/span\u003e\u003cspan address=\"10.1186/s12884-025-07796-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrokwa SK, Ruby LC, Heuvelings CC et al (2022) Task shifting for point-of-care ultrasound in low- and middle-income countries: systematic review. EClinicalMedicine 45:101333. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eclinm.2022.101333\u003c/span\u003e\u003cspan address=\"10.1016/j.eclinm.2022.101333\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBellows B, Totten J, Shah S et al (2015) Perceived barriers in point-of-care ultrasound use in WWAMI region. J Emerg Med Crit Care 1:4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalimi N, Gonzalez-Fiol A, Yanez ND et al (2022) Ultrasound image quality comparison between handheld and mid-range ultrasound machine. POCUS J 7:154. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.24908/pocus.v7i1.15052\u003c/span\u003e\u003cspan address=\"10.24908/pocus.v7i1.15052\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGithemo G, Wanyoro A, Masika J et al (2025) Evaluation of large-scale implementation of obstetric point-of-care ultrasound in Kenya using RE-AIM framework. BMC Health Serv Res 25:1016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-025-13212-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-025-13212-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"point of care ultrasound, digital health, perceptions, pregnant women, healthcare providers, low- and middle-income countries","lastPublishedDoi":"10.21203/rs.3.rs-9544997/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9544997/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUltrasound is essential for antenatal care (ANC), yet access remains limited in many low- and middle-income countries (LMICs) due to shortages of equipment and trained personnel. Point-of-care ultrasound (POCUS) offers a feasible solution for gestational dating, detection of high-risk conditions, and referral decision-making in these settings. Effective integration of POCUS into routine ANC requires understanding both healthcare providers\u0026rsquo; (HCPs) and pregnant women\u0026rsquo;s perspectives as a foundation for trust.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study was conducted at a peri-urban site in Karachi, Pakistan to explore the perception of obstetric POCUS among HCPs and pregnant women. In-depth interviews (IDIs) were conducted with purposely sampled participants until thematic saturation was achieved, comprising six pregnant women enrolled in an ongoing POCUS cohort study, and three HCPs performing POCUS. Interviews were audio recorded, transcribed, translated, and analyzed using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe six common themes identified were role of ultrasound, POCUS experience, benefits of POCUS, limitations and areas of improvement, myths and misconceptions, and recommendations for future use. POCUS was perceived as a valuable and feasible tool for ANC due to its portability and ability to perform rapid assessment closer to communities. Women valued reduced travel times while HCPs highlighted its user-friendly design and short learning curve for basic obstetric assessment and referral decisions. However, concerns regarding technical difficulties and diagnostic limitations were noted.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTargeted interventions focusing on structured training and community education may support effective integration of POCUS into routine ANC and improve access to obstetric imaging, with potential to improved maternal and neonatal outcomes in underserved communities.\u003c/p\u003e","manuscriptTitle":"Providers and Pregnant Women Perspective on Obstetric Point-Of-Care Ultrasound Use in Peri-Urban Karachi, Pakistan: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 13:35:37","doi":"10.21203/rs.3.rs-9544997/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-17T19:30:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30392889831009978797290718075339260230","date":"2026-05-07T13:50:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153959855700823032500681100142949057350","date":"2026-05-06T17:40:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-06T11:37:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-30T08:38:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-29T10:37:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-29T05:49:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Digital Health","date":"2026-04-29T05:45:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-digital-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Digital Health](https://bmcdigitalhealth.biomedcentral.com/)","snPcode":"44247","submissionUrl":"https://submission.nature.com/new-submission/44247/3","title":"BMC Digital Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"16637961-0864-47a8-aa54-9b8fc62508df","owner":[],"postedDate":"May 15th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-17T19:30:57+00:00","index":23,"fulltext":""},{"type":"reviewerAgreed","content":"30392889831009978797290718075339260230","date":"2026-05-07T13:50:37+00:00","index":21,"fulltext":""},{"type":"reviewerAgreed","content":"153959855700823032500681100142949057350","date":"2026-05-06T17:40:55+00:00","index":20,"fulltext":""},{"type":"reviewersInvited","content":"4","date":"2026-05-06T11:37:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-30T08:38:11+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T13:35:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-15 13:35:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9544997","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9544997","identity":"rs-9544997","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}