Implementation Barriers of Antenatal Ultrasound Services in Primary Health Care: A Scoping Review with Implications for Midwifery Practice

Abstract

Antenatal ultrasound is increasingly recognized as an important component of quality antenatal care, particularly for confirming gestational age, identifying multiple pregnancy, detecting fetal presentation, and supporting timely referral. However, the implementation of ultrasound services in primary health care remains uneven, especially in settings where antenatal care is largely delivered by midwives and frontline providers. This scoping review aimed to map the implementation barriers of antenatal ultrasound services in primary health care and explore their implications for midwifery practice. The review was guided by scoping review methodology and the PRISMA-ScR framework. Relevant literature published between 2021 and 2026 was considered from major health databases and complementary sources. The findings indicate that barriers extend beyond device availability and include infrastructure limitations, inadequate training and competency assessment, disrupted antenatal care workflow, weak referral systems, limited clinical governance, concerns about women’s acceptability, and sustainability challenges. These barriers are interrelated and may reduce the clinical value of ultrasound when implementation is not supported by clear protocols, supervision, counselling, and referral pathways. For midwifery practice, the findings highlight the need for competency-based training, supportive supervision, ethical communication with women, and integration of ultrasound into routine antenatal care rather than treating it as a stand-alone technology. Strengthening midwife-led ultrasound services requires a system-oriented approach that connects equipment, workforce, workflow, governance, equity, and financing.