Caring for Mothers with Ultrasounds, AI, and Nurse Midwives | Bill & Melinda Gates Foundation

In a small clinic in Nakuru County, Kenya, nurse Jane Waire sweeps a handheld ultrasound probe over her patient’s abdomen, looking for signs that the pregnancy is healthy: Is the placenta well positioned? Does the size of the fetus match its gestational age?  

Instantly, Waire sees an image of the fetus on a screen. The mother-to-be is bubbling with excitement—she knows immediately that it was worth traveling to the clinic that day. 

In high-income countries, ultrasounds are so routine they can be taken for granted. But elsewhere in the world, two-thirds of pregnant women don’t have access to them—sometimes with devastating consequences. Waire’s clinic only started providing this potentially lifesaving service in January 2023. 

Waire is part of an initial cohort of Kenyan nurses and midwives trained to use a new, more portable version of the ultrasound machine, designed specifically for the needs of low- and middle-income countries. This powerful handheld device is straightforward to operate. The wand is connected to a tablet computer, not a bulky machine. The device is about 5% of the cost of larger machines. And soon, such devices will incorporate artificial intelligence (AI) capabilities, making them even more agile in identifying pregnancy risk factors. 

Our foundation, has been working in partnership with many other organizations, researchers, and clinicians so more pregnant women around the world can have the benefit of ultrasounds. As a pediatrician who’s spent many years working on public health, I couldn’t be more excited. But the real key to this effort is the work of nurses like Waire.  

Nurses and midwives in low-resource settings do a remarkable job with the tools they have. With their education and experience, they can learn a lot just by using their own senses. They use their ears to detect the fetal heartbeat. They use their hands to palpate across a woman’s abdomen to determine the baby’s position.  

But sometimes those techniques are not enough. “Even if you’re experienced, you miss some things,” Waire says, because nurses can’t see inside the womb.  

For decades, ultrasounds have been the cornerstone of pregnancy management in high-income countries because they can identify high-risk pregnancies early, allowing clinicians and families to plan ahead and mitigate risks. In one study, researchers estimated that fetal deaths declined by 20% after ultrasounds were introduced. In low- and middle-income countries, they’re often available in higher-level facilities in larger cities, but are historically unaffordable for community clinics like Waire’s.  

Without ultrasound, there are things you simply cannot know—like the amount of amniotic fluid. That uncertainty is unsettling for health care providers, and it’s dangerous for mother and child. For example, trying to deliver a baby in the breech position can lead to hemorrhage and even death.  

These risks are very real for women in labor in low- and middle-income countries, where 94% of maternal deaths and the vast majority of newborn deaths occur. Waire’s clinic doesn’t have an operating theater or a doctor—in fact, most women in these areas don’t ever see a doctor during pregnancy. If anything goes wrong during labor, Waire’s patients often endure a 30-minute wait for an ambulance to take them to a higher-level facility 35 kilometers away. That wait can be the difference between life and death.  

Scientific advances have helped cut in half the number of children under age 5 who die each year. But advances in maternal and newborn health have lagged.  

Thanks to portable and lower-cost devices, more midwives can provide ultrasounds in the clinics that need them most. 

Getting ultrasound devices into midwives’ hands is critical. That’s why our foundation has been funding research to develop several next-generation ultrasound devices and has partnered with companies developing them. But new technology alone cannot solve the problem. Health workers must be available and well trained. And everyone involved must see a benefit. For that reason, the companies we’re working with include nurses, midwives, and patients as an integral part of the development process.  

Grace Kirigo Githemo, a researcher at Kenya’s Kenyatta University, is running a study to see how the devices affect maternal and newborn services in small clinics in that country. Her team selected regions with the highest maternal and newborn mortality rates and trained 500 local nurses and midwives to identify five high-risk conditions using the portable ultrasound. The providers were instructed to refer patients with risk factors to a higher-level facility for diagnosis by more extensively trained sonographers and further medical attention. After five days of training, the nurses and midwives went back to their clinics with the devices. 

Six months later, Githemo’s team began visiting the clinics to see how things were going. Since the midwives didn’t receive ongoing mentoring, she wondered whether they would struggle or even put the devices aside. She was delighted by what she found. 

“The midwives are very motivated” to offer ultrasounds, she says. There have been some hurdles, like software updates and shortages of ultrasound gel, both of which are being addressed. But all in all, Githemo reports that “the technology makes decision-making faster, easier, and more accurate.”  

Waire says the difference truly feels profound. “Before, there were things we could not evaluate at all, such as where the placenta is located,” she says. “We couldn’t always feel sure about our decision-making. Now, with the ultrasound, we can be 100% sure. We can make a quick diagnosis before it’s too late.” 

The midwives told Githemo’s team that they were able to identify breech babies. In one case, the device revealed that a pregnant woman was unknowingly carrying triplets—something very hard to identify without technology, and extremely risky for normal delivery. They were able to confidently assess whether the woman needed a referral to higher-level care.  

“One facility told me that for the last six months, they had not had a fetal death,” Githemo says. “It was very encouraging.”  

Waire, Githemo, and others hope that portable ultrasounds become the norm in community clinics in countries like Kenya. “We’d like to see a policy that ensures every midwife has a handheld probe,” Githemo says. That’s where the next big advancement in technology may help.  

While the training takes just five days, scaling up to train tens of thousands more midwives would be a monumental task. But we’re partnering with several companies that are working on AI-enabled devices that we hope will make the technology even easier to use and require less training.  

This AI involves basic machine learning. Essentially, the machines are trained with thousands of existing ultrasound images that have been reviewed and annotated by sonographers to train algorithms that identify specific risks. Midwives sweep the ultrasound probe across the woman’s belly several times while the algorithm runs in the background. After a short exam, the device can flag whether the pregnancy is high risk, and the nurse or midwife can then provide recommendations to the woman on the location, content, and frequency of care that she needs.  

The algorithms are now being honed and tested in the field. So far, researchers have found that the AI does a good job identifying high-risk pregnancies. One study found that the AI-enabled devices can estimate one key data point, gestational age, with more accuracy than humans.  

“It will revolutionize midwifery in this country,” Githemo says.  

Dr. Beatrice Murage, director of sustainability and health equity at one company we are working with in this effort, sees ultrasounds as benefiting not only individual families but entire communities. As a doctor practicing in rural Kenya, she has lost mothers during delivery. She has seen others left with life-altering consequences after pregnancy complications—everything from debilitating depression to major surgeries and devastating fistulas.  

“When a mother gets good care for her and her baby, that touches on so many of the Sustainable Development Goals: gender equity, health, poverty,” Murage says. “Bringing this kind of care closer to the mother is really an ecosystem story. The potential is really large.” 

We expect to see regulatory approval for these devices in the next two years. In the meantime, our foundation and others are working on how to quickly get the device into more midwives’ hands after that.  

When developing technology like this, the main goals include, most obviously, identifying risky pregnancies to save the lives of mothers and babies. We’re hopeful that the number will ultimately be in the millions. But patients are experiencing other benefits, too.  

Veronica Fulano Nato, a nurse trained by Githemo’s team, says ultrasounds are changing the way mothers-to-be think about their pregnancies. Before, it wasn’t unusual for a pregnant woman to wait until she began labor to make her first visit Nato’s clinic in Kilifi, Kenya. That’s a problem because Nato would have to spring into action without knowing anything about the pregnancy. Were mother and baby healthy? Was the delivery high risk? If something goes wrong at the clinic, getting the woman to the hospital can take an hour. Now, women are starting to come to the clinic earlier in the pregnancy, eager to see the ultrasound images and confident they’re getting state-of-the-art care.  

“They’re so happy,” Nato says. “They say, ‘It feels like we’re at a big-city hospital.’”  

With the help of ultrasounds, Nato has more confidence in her assessments. That allows her to give better information to the referring hospital. 

“If I say I’ve done the ultrasound and the client has this danger, the ambulance comes so fast,” she explains. Mothers-to-be are also more willing to make the costly journey when they need further care. “With the results, they know this is a dangerous situation and that we need to act fast,” says Nato. 

Over the longer term, we expect that this positive experience will have ripple effects. A family’s view of the health system has a lot to do with the mother’s experience with prenatal care. The better the experience, the more likely the family will be to come back for family planning services, nutrition services, immunizations, and treatment for childhood illnesses. 

It’s also clear that healthy families build thriving communities. Nato sums it up this way: “Our work has been made easier and better. We know that our level of neonatal and maternal deaths are going to decline.” 

Waire agrees. “Now,” she says, “our mothers are getting the very best.” 

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