Portable AI Ultrasounds Curbing Maternal Mortality in Sierra Leone

Every woman has the right to receive excellent care before, during, and after pregnancy. The World Health Organization (WHO) recommends having at least one routine ultrasound before the 24th week of pregnancy to ensure a positive pregnancy experience. In 2016, WHO added a single ultrasound scan before 24 weeks of pregnancy to its list of recommended interventions for routine antenatal care (ANC). In most high-income countries, routine antenatal ultrasound screening has been standard practice for some time, often being conducted in both the first and second three months of pregnancy.

“One ultrasound scan before 24 weeks of gestation (early ultrasound) is recommended for pregnant women to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce induction of labor for post-term pregnancy, and improve a woman’s pregnancy experience. This helps to minimize adverse maternal outcomes, such as mortality, ” says Khadija Tolo, a Community Health Worker (CHW) at Yele Health Centre in Sierra Leone.

Maternal conditions directly impact perinatal outcomes, and up to 37% of patients are potentially misdiagnosed. The incorporation of ultrasound services in their care can correct this.

“Ultrasound services can also help identify conditions that might otherwise be missed, leading to adverse outcomes like placenta previa, adherent placenta, undiagnosed multiple pregnancies and malpresentations. This recognition can result in life-saving interventions for up to half of pregnant women,” adds Khadija.

Currently, portable point-of-care ultrasound technology is now being utilized in various low-income countries worldwide, contributing to improved maternal care. Sierra Leone is one of these countries. The West African nation has adopted Baby Checker, an artificial intelligence (AI) ultrasound solution which can be accessed through smartphones.

Sierra Leone, officially the Republic of Sierra Leone, is a country on the southwest coast of West Africa. It shares its southeastern border with Liberia, and the northern half of the nation is surrounded by Guinea.

“BabyChecker is an artificial intelligence software that detects different potential pregnancy risks by any community health worker, midwife or nurse in primary healthcare,” says Enya Seguin, the Developer and Unit Manager of BabyChecker at Delft Imaging. “We have pioneered Artificial Intelligence for fetal ultrasound screening. With the novel technology, pregnant women in underserved communities can have safer pregnancies through improved maternal health screening.”

Enya Seguin explaining how babychecker works (Photo by Africa Health Business)

“When we say BabyChecker, we don’t just mean the software but the hardware as well. This includes an Android smartphone with a charger, an already installed BabyChecker app, and a probe. The app itself is not on any app store. Simply put, whenever someone wants it, we send the whole kit consisting of the smartphone (charger included), installed with the BabyChecker app, and a probe. This also means the users don’t have to connect or install anything. They can start using it right away. The app itself comes with a subscription that can be renewed upon expiry. The hardware set is a one-time purchase of Є3000, and the software is another Є3000.” says Katyayini Singh, the Content Specialist at Delft Imaging.

Katyayini Singh, the context specialist at Delft Imaging (Photo by Delft Imaging)

According to Enya, ultrasound imaging is considered a more challenging medical equipment, even by medical professionals. A lot of training is required. That’s because ultrasound imaging is a moving image that is created by the accurate and knowledge-driven placement of the ultrasound probe on the specified part of the body. Since such human capacity is scarce in low-resource settings like Sierra Leone, maternal and antenatal health is being deprived from the benefits that ultrasound imaging can offer when preventing maternal and antenatal complications.

“While clinicians can now travel everywhere with portable ultrasounds, there’s still the challenge of inadequate medical persons who are trained to operate the machines. That is where AI comes in,” explains Enya.

“Crafted with the aim of resource efficiency, any healthcare worker with minimal to no ultrasound experience can perform scans within an hour after watching a 3-minute tutorial video. Plus, it can be accessed offline, so there is no need for a constant internet connection. This makes it highly convenient for low-resource settings. The user has to do six sweeps across the expecting mother’s abdomen with the probe, as directed in the app. The community health worker gets the ultrasound images within two minutes with just these six sweeps. The AI analyzes the images, instantly identifying the gestational age, fetal presentation, twin pregnancies, and placenta localisation.”  says Katyayini.

An illustration by Delft Imaging on how to use BabyChecker.

Enya adds that the video tutorial on the BabyChecker app is enough for any health worker to learn how to use it and that no additional training is required. However, in some cases, the Delft Imaging team can introduce the device in person, but even that lasts up to 15 minutes.

According to Delft Imaging, more than 2000 pregnant women have been scanned by BabyChecker since its adoption in Sierra Leone. Also, over 20 CHWs have had the chance to utilize it in very remote areas of the country. Zainab Husla, a CHW in Mafay Manowo Maternal & Child Health Post is among the group of CHWs that are using BabyChecker.

“BabyChecker helps us know how the child is doing in the mother’s womb. Whether doing fine or not. If the baby is fine, then it’s okay. If not, then we refer for further care,” she says while adding that she checks about 15 to 25 women in a day.

The CHWs also link referrals for continuous care. “We refer immediately and follow up with the patient and the referral hospital. They, in turn, contact us if the woman needs follow-up attention at the Peripheral Health Unit (PHU),” says Husla.

Zainab Husla from Mafay Manowo Community Health Center screening Tenneh Jolloh, Sierra Leone. (Photo by Delft Imaging)

While referring pregnant women for further attention, the BabyChecker ultrasound images are attached. “The scanned images are provided to the application, which the CHW can easily share via WhatsApp, screenshot, Bluetooth or any other transfer technology. These images can also be printed in a classical printer. The nature of the results is mostly a triage to ensure the baby’s health is okay.” says Enya.

“The introduction of BabyChecker in Mafay in Manowo Maternal & Child Health Post has truly transformed our prenatal care experience. When I first learned about it, I was a bit skeptical, but now I can’t express how grateful I am. The technology has allowed for more comprehensive and early screenings. During my last check-up, the AI detected a minor complication that could have escalated without intervention. CHW Zainab Husla was able to refer me for further medical attention in time,”says Tenneh Jolloh, a resident,  adding that the medical team addressed the issue promptly, ensuring her well-being and that of her unborn child.

In Gbonkolenken Chiefdom, Khadija Tolo, a CHW at Yele Community Health Center receives about 22 pregnant women daily. “The BabyChecker determines potential risky pregnancies and deliveries. It Identifies gestational age, fetal abnormalities, twins, placenta position, fetal lie, and a viable pregnancy.” she says. In regard to its usage, Khadija describes it as “an easy-to-use device with a very simple tutorial and clear instructions.”

Khadija Tolo Jusu screening Mariatu Turray at Yele Community Health Center. (Photo by Delft Imaging)

“As a soon-to-be mother in a remote area like Gbonkolenken, accessing specialized medical services can be a challenge. However, with the introduction of BabyChecker, it feels like we have a skilled medical professional right here with us. The detailed imaging and analysis provided by the AI have now given me peace of mind. I can now confidently say that our pregnancies are in safer hands,” says Mariatu Turray, an expectant woman, who attends ANC at Yele Community Health Center.

In an era of groundbreaking technological advancement, AI has emerged as a powerful tool with immense potential to transform global health equity, especially in low and middle-income countries.

“BabyChecker is over 85% accurate in showing placenta localisation. Our gestational age accuracy has a mean absolute error of 5 days. This means that since gestational age is given in weeks, it could be plus or minus five days different.” says Enya.

“This is a unique innovation for saving the lives of mothers and babies during pregnancy. Women around Kono, one of our health facilities in Sierra Leone now recognise the accuracy of machines in generating correct diagnoses with minimal or no errors. This has resulted in a substantial increase in the number of women seeking healthcare services. The positive perception of the scan’s reliability has played a significant role in motivating women to avail themselves of healthcare.” said Karlin Bacher, the Director of Clinical Quality Improvement at Jericho Road Community Health Center during a BabyChecker webinar held in December 2023.

According to the Program for Appropriate Technology in Health (PATH), AI can support health workers with timely insights that inform better decisions and improve patient outcomes even in resource-constrained settings. At the health systems level, AI has the capacity to enhance interventions like disease surveillance, supply chain optimization, and diagnostics, thereby accelerating progress toward health for all.

While BabyChecker is a spectacular solution, its implementation in Sierra Leone has not been all rosy. “Access to enough funding has been a challenge. A lot of big companies now have received funding to develop AI, to work on ultrasound solutions. We need to collaborate because something as impactful as BabyChecker should be able to penetrate in all parts of Africa,” says Enya.

Enya Seguin, the Developer and Unit Manager of BabyChecker at Delft Imaging. (Photo by Delft Imaging)

Fatou Musa, a CHW in Warema Health Centre says that most villages with the community health centers do not have internet or electricity. “It is good that BabyChecker does not need the internet to process images. The ultrasound probe does not also require a separate charging port. Once you charge the smartphone, it is good to go.”

In 2017, Sierra Leone was among the top three countries in Africa with high maternal mortality. It recorded 1 maternal death in every 89 births in the country. In 2020, the maternal mortality rate dropped by nearly 60%.

Maternal Mortality Ratio per 100000 Births in West Africa (Visualization by Treezer Atieno)

Currently, Sierra Leone is one of the top countries in Africa with an availability of ANC services, family planning services, safe blood transfusion items (infusion pumps, blood warmers and rapid infusers) and essential medicines like heat stable carbetocin, oxytocin, misoprostol, tranexamic acid, magnesium sulfate.

According to Integrated African Health Observatory (IAHO), Maternal Mortality remains a key issue affecting women of reproductive age across the African Region. Despite the global decline in the maternal mortality ratio (MMR) to 34.2% between 2000 and 2020, MMR is still a disaster in the Africa region.

In West Africa, Cape Verde is the only country with low maternal mortality, estimated at 42 per 100,000 live births. The rest of the countries are categorized either in high, very high or extremely high maternal mortality rates. Sierra Leone has moved from the very high category to the high category.

WHO records show that obstetric hemorrhage is the leading cause of maternal mortality in Africa. Other causes are hypertensive disorders during pregnancy, non-obstetric complications, pregnancy related infections and pregnancy with abortive outcomes.

Leading causes of Maternal Mortality in Africa (Visualization by Treezer Atieno)

Apart from an ultrasound screening, ANC is also considered as a very crucial step in overcoming maternal mortality. According to Global Health Observatory, ANC coverage is an indicator of access and use of health care during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their infants. Receiving antenatal care at least four times increases the likelihood of receiving effective maternal health interventions during the antenatal period.

“Fetal scans here in Warema are now popular and this has resulted in more pregnant women attending antenatal care (ANC) and giving birth in health facilities. This increase in ANC attendance has made it easier for us to provide other health interventions like TT (Tetanus Toxoid), malaria checks and more,”notes Fatou.

In 2020, Integrated African Health Observatory (IAHO) recorded that most women in West African countries attended four ANC visits that year. The average attendance was 60%. Sierra Leone ranked fifth out of 16 in four ANC visits by pregnant women with 78.80%.

Percentage of women who attend 4 ANC visits in West Africa (Map by Treezer Atieno)

“Through antenatal care visits, pregnant women can also access micronutrient supplementation, treatment for hypertension to prevent eclampsia, as well as immunization against tetanus. Antenatal care can also provide HIV testing and medications to prevent mother-to-child transmission of HIV. In areas where malaria is endemic, health personnel can provide pregnant women with medications and insecticide-treated mosquito nets to help prevent this debilitating and sometimes deadly disease,” reads a 2022 United Nations Children’s Fund report(UNICEF).


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