Evaluation of antenatal Point-of-Care Ultrasound (PoCUS) training: a systematic review

Figures & data

Table 1. General PoCUS workshop requirements and methods for assessing competence

General workshop requirements defined by *ASUM[31,32]	Methods for assessing competency in PoCUS[33]
Faculty- must include a medical specialist with appropriate and extensive clinical experience/qualifications. Instructors must have significant practical experience in the application being taught. Registered sonographers can assist with teaching skills.	Technical competency assessment- Probe selection, image mode selection (e.g., cardiac, obstetric), proper image orientation, probe positioning, depth, gain, centering of target structure, demonstrates advanced functions (M-mode, Doppler, image capture), troubleshooting.
Teaching (including practical) hours should at least meet those published in credentialing syllabus for the application taught.	Knowledge assessment- Course entry assessment following pre-reading Pre and post course assessment Multiple-choice questions Written answer
Provision of course syllabus, learning materials, recommended texts and other references.	Objective Structured Clinical Examination (OSCE) / Practical examination.
Instructor to candidate ratio 1:5.	Standardised checklists for evaluating technical skill.
Machine to candidate ratio 1:5.	Skill assessment on simulator, model, or standardised patient.
Appropriate models and patients.	Review of images obtained on real patients.
Setting to accommodate lectures and practical scanning sessions.	Real-time assessment of scanning actual patients and clinical decision making.
Pre- and post-course tests.	Longitudinal patient evaluation and periodic review to assess image quality and accuracy of PoCUS interpretation.
Evidence of attendance including course hours.	Self-assessment- Knowledge/skill Perceptions/attitudes Change in work behaviour/scanning frequency

*ASUM- Australasian Society for Ultrasound in Medicine.

Table 2. Eligibility criteria

	Include	Exclude	Rationale for exclusion
Population	Health care clinicians/practitioners- Nurses, Midwives, Doctors, Allied health workers, students from all health disciplines.	Sonographers Non-health professionals.	Sonographers and trainee sonographers possess more advanced imaging skills and are not within the scope of this review. Focus on training of populations with minimum basic healthcare training/experience/qualification. It is not advisable for non-healthcare professionals without training to perform PoCUS on patients/people.
Intervention/ Exposure	Antenatal Point-of-Care ultrasound (PoCUS) training including broader courses teaching scanning of multiple organ systems.	PoCUS training with no antenatal specific content (e.g., critical care- FAST, Abdominal, cardiac, lung, vascular). Advanced training (complex and interventional scanning) or full diagnostic ultrasound training leading to registration and qualification (sonographer training).	Non-antenatal PoCUS training is beyond the scope of this review. This review is focused on basic PoCUS training of health professionals. Advanced training such as those requiring lengthy courses, long-term supervision and formal accreditation/registration are beyond the scope of this review.
Outcome	Efficacy of training.Types of evidence/evaluation measures: Training course evaluation/Trainee satisfaction, testing of knowledge and practical skills (OSCE), Image quality review, diagnosis review, Confidence measures, Scanning frequency, Maternal/fetal outcomes.	Articles with limited description or reporting of the training intervention (training delivered), training assessment (evaluation measures) and outcome.	Inadequate methodological detail inhibits quality assessment and comparison between studies.
Study type	Original research. Studies involving antenatal PoCUS training evaluation- Cohort studies, cross-sectional studies, case control studies, observational studies, qualitative studies, case reports, clinical and randomized control trials. English language. Clinical/Human studies.	Review articles, Conference presentations/Abstracts, Letters, Editorials, Commentaries.Articles with Insufficient detail of described training interventions (training delivered), training assessment (evaluation measures) and outcome. Non-English articles. Animal studies.	Only original research articles were included for review. Conference presentations and abstracts (not full length articles) provide insufficient detail and peer-review scrutiny.

Figure 1. PRISMA framework – Search results.

Table 3. Key outcomes investigated and findings

First author Year Published	Key outcomes investigated		Main Finding in relation to antenatal PoCUS
Adler [66] 2008	Frequency & application of PoCUS following training.		Pregnancy-related exams accounted for 24.1% of total. US is a feasible & sustainable imaging modality in a very low-resource setting (refugee camp).
Baltarowich [61] 2009	Trainee knowledge acquisition & retention – written test scores compared at 3 points in time over 6 months.		Mean test scores increased significantly- 58.4% at entry to 76.8% at end-of-program. Nine of the 12 physicians were selected to establish affiliated US training programs in their own country.
Bell [22] 2016	Written & practical test scores; before & after refresher training. Frequency & application of PoCUS following training. PoCUS impact on patient management.		Strong correlation between knowledge & practical skill scores. Increase proportion passing both knowledge & practical tests at follow-up, compared to initial session. 90% trainees completing more than 1 session maintained or improved scores. Follow-up survey- 2/3 to 3/4 reported using PoCUS over 20 times in previous 3 months, Obstetrical exams were most commonly performed and had the greatest impact on patient management.
Dalmacion [25] 2018	Trainee to instructor image comparison. Estimate of maternal/fetal deaths averted.		95% agreement between the trainee & instructor US. Estimated 6.3% of maternal deaths & 14.6% of neonatal deaths possibly averted by the early US screening.
Dornhofer [54] 2020	Pre- & post-course written & practical examination scores (compare physicians, nurses, & midwives). Post-course survey of trainee scanning confidence.		No participants passed (>65%) the pre-course examination. 43 (72%) passed the course & 12 (28%) failed. Written exam pass rate- Fifteen (79%) physicians, 11 (85%) nurses, & 13 (68%) midwives. Average practical examination score was 83% (SD = 16.2%) for physicians, 82% (SD = 11.4%) for nurses, and 71% (SD = 15.2%) for midwives. Physicians performed best on pre- & post course written exams, followed by nurses & then midwives. Nurses scores improved most, followed by physicians & midwives. The average practical score for physicians was significantly greater than midwives (P = .038). The average practical score for nurses was significantly greater than for midwives (P = .049). All trainees reported increased post course comfort levels performing PoCUS.
Henwood [53] 2017	Expert review of trainee images. PoCUS application. PoCUS impact on patient management.		100% sensitivity & 98% specificity for expert reviewed OB images (94% & 98% overall). Trainees most frequently used US for abdominal & OB applications. 81.3% of patients had at least one clinical decision changed because of a PoCUS.
Kimberly [62] 2010	Practical assessment (OSCE) of skills & sustainability over time (2 & 6 months). Expert review of trainee images. Frequency & application of PoCUS following training. PoCUS impact on clinical decision making/patient management.		Paired OSCE scores- slight overall improvement over time. Trainees most competent at identifying number of gestations (100%), & fetal presentation (96%), calculating FHR (48%) was more challenging. Scan review- FHR interpretation 96% agreement, placental location 91% agreement, BPD 70% agreement. Mean of 21 scans performed per trainee over 6 months. 2^nd & 3^rd trimester most common. Main indications recorded- Size to date discrepancy (44%) & determining fetal position (39%). US prompted change in clinical decision-making in 17% of cases. At 1 year follow-up- trainees average 10 PoCUS per week. 85% reported helping colleagues use US. 46% reported significant time constraints as main limitation.
Kolbe [26] 2015	Expert review of trainee images. PoCUS application/indication. PoCUS impact on clinical decision making/Patent management.		Average expert rating of trainee images-6.54/10 in first 6 weeks & 7.17/10 in last 6 weeks. 52% (CI- 44-61%) of patients had a new diagnosis after PoCUS. A new diagnosis lead to change in management in 48% (CI 40–57%) of patients.
Kotagal [56] 2015	Change in self-assessment scores regarding attitudes, confidence & assessment of the value of US before & after training intervention.		Mean confidence score pre-test to post-test improved from 23.3 (±10.2) to 37.8 (±6.7). Before & after training, trainees overwhelmingly agreed US would improve their practice, make them a better surgical resident, & improve their practice in LRS. All agreed the US course helped them improve their PoCUS knowledge & skills.
Lathrop [58] 2011	Learner portfolio & hands-on workshop for US credentialing & training. Learner feedback meeting.		All 4 trainees credentialed to perform US clinically within one month. Portfolios & evaluation rubric offered a consistent, systematic means to demonstrate the acquisition of skills for clinical practice. And were a more effective & practical method of demonstrating trainee competence & supporting credentialing over a physician’s subjective impression of trainees’ abilities.
Lee [55] 2017	Pre & post course trainee knowledge assessment. Post training practical skills assessment and course evaluation survey (scanning confidence & intent-to-use US).		Average pre-course exam score was 35.2% (2.4% pass rate). The average post-course exam score was 82.0% (92.7% pass rate). Average practical score on completion of the course was 83.2% (SD = 0.145) with 82.9% of the class passing (pass mark above 75.0%). Post-course survey- overall increased level of comfort performing all scans. Cardiac followed by OB US were anticipated to be most frequent indication.
Lindgaard [52] 2017	Expert review of trainee images.		Expert to trainee agreement for intrauterine pregnancy-100%, GA- 93%. Low-to-moderate complexity PoCUS exams performed by GPs with sufficient prior training have a very high level of inter-rater agreement when compared to exams conducted by radiologists & gynaecologists.
Mandavia [67] 2000	Trainee knowledge acquisition & retention- written test scores before & after training & at 10 month follow-up (stratified by discipline & US experience). Expert review of trainee images. Frequency & application of PoCUS.		The mean pre-test score was 65%, mean post-test score 84%, No decline after 10 months. Pre-test variation based on US experience not evident after training. Image review- overall sensitivity of 92.4% & specificity of 96.1% (95% CI = 94% to 98%). OB only exams were 94% sensitive & 100% specific. Frequency of scanning varied widely (9–152), averaging 62 exams over 10 months. Biliary, renal and trauma were the most frequent indications for scanning.
Nathan [49] 2017	Written & practical skills assessment. Expert review of trainee images for errors in scanning parameters & diagnosis, using predetermined criteria. Site, patient & trainee demographics.		36/41 trainees passed the practical test on first attempt at the end of 2 week course & 40/41 passed at the end of 12 week pilot period. Mean practical skills score increased- 78% on the first test to 92% on the fourth test. Of the 3801 US exams (32,480 images), 94.8% were rated as satisfactory by expert review. Concordance between trainee & reviewer US diagnosis was 99.4%. High-risk pregnancies were identified by the trainees in 6.7% (255/3801) of exams.
Rominger [24] 2018	Frequency & application of PoCUS following training. Expert review of trainee images. Impact on patient management & diagnosis.		The most common studies were TA OB exams (45.5%) and abdomen/pelvis (26.6%). US scanning peaked after teaching sessions then gradually decreased over months. Highest recorded scans were after the final teaching session. Disagreement in findings in 4.3% of the images reviewed (none affected clinical management) & 6.5% with inadequate image quality to interpret. PoCUS changed patient diagnosis in 34% (24% for OB patients) & clinical management in 30% (20% for OB patients). In the scans that changed the diagnosis, 78% led to changed clinical management.
Shah [45] 2020	Practical OSCE assessment & accuracy of images & measures over time. Blinded expert image review for QA & inter-rater reliability of reviewers. Confidence levels pre-post training & at 3 months follow up. Post course evaluation/training perception interviews.		Of 25 trainees, 22 passed (average score 89.4%) the OSCE on first attempt. Image quality improved with time; the final error rate at week 8 was less than 5%. Confidence levels increased- pre-course 1 point average to over 6 points post-course for all measures (maximum 7). Key informant interviews- indicated a desire for more hands-on training, longer training duration & challenges in balancing clinical duties with ability to attend training sessions.
Shah [48] 2014	Pre- & post-course knowledge & confidence assessment. Time & accuracy of scanning.		For previously untrained trainees, pre- & post-test knowledge scores improved from 65.7% [SD = 20.8] to 90% [SD = 8.2] (p < 0.0007). Self-confidence improved significantly for identification of FHR, fetal lie, & EGA. Average times for completion of critical skills: cardiac activity (9s), FHR (68.6s), fetal lie (28.1s), & EGA (158.1 sec). EGA estimates averaged 28w0d (25w0d-30w0d) for the model‘s true GA of 27w0d.
Shah [47] 2009	Reporting impact of previously published training program (Shah 2008) Patient demographics & US application. Blinded expert image review of trainee images for quality & accuracy. PoCUS directed change of patient management.		OB scanning was the most frequently used application followed by abdominal. Evaluation of GA, fetal head position, & placental positioning were the most common findings. Local staff performed 245 US scans in the 11 weeks after the departure of the US instructor. Expert to trainee agreement on scan review of 96%. US changed patient management in 43% of patients.
Shah [46] 2008	Initial US needs assessment, training curriculum development & implementation. Staff survey of prior US experience & hospital records review.		10 of 15 physicians completed the training. Needs assessment-all 15 trainees rated OBs most important application. Focus group discussion- barriers to US services included distance, time & cost for transfers, lack of monitoring during transfers & US charges. Dissatisfaction expressed US report quality & inability to view images with written reports.
Shaw-Battista [29] 2015	Pre & Post course knowledge assessment. Post course evaluation. Other project evaluations/outcomes ongoing & not reported including: pre- & post-online module knowledge of OB US, interprofessional competencies, & post-training knowledge following seminar & practical.		Course evaluations were extremely positive. Trainees expressed enthusiasm to develop basic US competencies & recognised the applicability of new skills to clinical practice. Hands-on sessions were universally appreciated- requests for additional or longer sessions, more pregnant volunteers & reducing group size (trainee to faculty ratios). Trainees reported teaching varied types of trainees together as “innovative & helpful” but also perceived to be challenging.
Shokoohi [51] 2019	Trainee demographics including US experience. Frequency & application of PoCUS following training. Teaching of other staff/students. Challenges/barriers to integrating US into patient care.		Main applications for PoCUS- cardiac exams followed by 2nd & 3rd trimester OB exams. Over 75% reported use of PoCUS in clinical diagnoses & 50% in determining treatment. 50% reported very frequently or often using US to teach within their clinics. Largest perceived barriers- lack of clinical educators US knowledge, lack of time, equipment security, difficulty accessing the Internet & equipment problems.
Stolz [30] 2015	Frequency & application of PoCUS over duration of training course. Patient/scan outcome.		Of 22,639 ED patients evaluated, PoCUS examinations were performed on 1,886 patients. OB scans (9.3%) were 3rd most common scan after FAST (53.3%) & Echo (16.4%). PoCUS studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all PoCUS exams.
Swanson [85] 2014	Expert review of trainee images. Diagnostic outcome following PoCUS.		Expert review of trainee images- 100% sensitivity & specificity for identifying gestational number, 90% sensitivity & 96% specificity for fetal presentation. Trainee PoCUS altered clinical diagnosis in up to 12% of clinical encounters.
Vinayak [63] 2017	Post e-module assessment (pre hands on) & post course written assessment. Expert review of trainee images for quality & accuracy of interpretation. Patient outcome following PoCUS. Patient experience.		E-module knowledge reported useful. All trainees passed the written post-course exit exam on 1st attempt. Reporting accuracy of trainees’ scans was 99.63%. Reduced AFI missed on 2 patients scans. Time to complete scan halved after completing 30 scans. All 246 patients felt the process was safe, convenient & reassuring, had a better antenatal visit experience & increased confidence in care delivery. More spouses attended then for routine antenatal visits.
Vyas [70] 2018	Post-training OSCE practical assessment. Image quality review & trainee identification of pathology. Patient outcome.		Trainees were able to correctly identify fetal presentation, fetal number, & placental position in all enrolled patients. BPD correctly assessed in 95.3% & HC 90%. GA had a mean difference from expert sonographers of 1.5 days (BPD) & 0.26 days (HC). All 4 patients with abnormal findings were expert confirmed.
Wanjiku [21] 2018	Pre-training knowledge assessment. OSCE practical assessment with image quality scores. Frequency & application of PoCUS following training.		OB images received the highest mean image quality score (compare to FAST, thoracic & echocardiography). Image quality scores increased with an increase in training sessions and decreased with increasing time since prior training. OB US were most frequently performed. Frequency of scanning positively correlated with written & image quality test scores.
Westerway [50] 2019	Trainee knowledge acquisition & retention – written & practical tests before & after training & at 6/11 month follow-up.Comparison of PoCUS courses (rural/urban sites, duration, student numbers).Course evaluation- satisfaction, engagement, understanding & relevance of learning. Scanning on return to work.		Practical assessment at 6/11 months- minor prompting for image optimisation (depth, gain & imaging plane for fetal biometry) for all but 4 trainees who had peer support at work following training. All (55) trainees achieved the course objectives, regardless of format. Course evaluation- all trainees stated understanding what was taught & relevance to their clinical work. All trainees continued scanning on return to work.
Abbreviations AFI- amniotic fluid index BPD- Biparietal diameter CI- Confidence interval d- days ED – Emergency Department EGA- Estimated gestational age		FAST- Focused assessment with sonography in trauma FHR- Fetal heart rate GA- Gestational age HC- Head circumference LRS- Low-Resource-Setting OB- Obstetric		OSCE- Objective Structured Clinical Examination PoCUS- Point-of-Care Ultrasound QA- Quality assurance SD- Standard deviation US- Ultrasound w- weeks

Figure 2. Of the included studies in the review a. Curriculum delivered (Multiple organ systems taught or Obstetrics and gynaecology only); b. Number of professionals trained (total recruited and trained per study); c. Ultrasound experience of trainees prior to undertaking the training; d. Discipline/role of the trainees (Multidiscipline/Physicians/Nurses/Midwives).

Table 4. Trainee & course evaluation

First author Year Published	Trainee feedback/survey Course evaluation, Scanning confidence, Training needs assessment, Patient feedback	Pre/post course theoretical knowledge assessment	Practical/OSCE assessment	Expert image review	Frequency and/or application of PoCUS	Patient outcomes & management
Adler [66] 2008	X	X	Minimum 20 supervised US examinations. No structured OSCE or knowledge exam.	X	Frequency & application of PoCUS following training.	X
Baltarowich [61] 2009	X	Identical test at program entry, course completion & 6 months follow-up.	X	X	X	X
Bell [22] 2016	X	Pre course test- open book 90% pass mark for enrolment.	OSCE- assessing image interpretation & quality.	X	Follow-up survey of US use.	PoCUS impact on patient management.
Dalmacion [25] 2018	X	Pre & post Knowledge test.	X	Expert review of trainee images.	X	Estimate of maternal/fetal deaths averted following PoCUS.
Dornhofer [54] 2020	Post course survey to assess scanning confidence & provide course feedback.	Identical pre & post course knowledge test.	Post course practical test on image acquisition & interpretation.	X	X	X
Henwood [53] 2017	Pre-training needs assessment.	X	Image based assessment & post course OSCE. Regular practical assessment over 6 month follow-up.	Expert review of trainee images.	Frequency & application of PoCUS following training.	PoCUS impact on clinical decision making/patient management.
Kimberly [62] 2010	X	X	Practical assessment (14 item OSCE) of skills & sustainability over time (2 & 6 months).	Expert review of trainee images.	Frequency & application of PoCUS following training & teaching colleagues.	PoCUS impact on clinical decision making/patient management.
Kolbe [26] 2015	Pre-training needs assessment.	X	X	Expert review of trainee images.	Application of post training PoCUS.	Change in patient diagnosis & management following PoCUS.
Kotagal [56] 2015	Pre & post survey to measure trainee confidence.	X	X	X	X	X
Lathrop [58] 2011	X	X	X	Learner portfolio & images reviewed using rubric to evaluate progress, knowledge & skills prior to credentialing.	X	X
Lee [55] 2017	Post course evaluation survey.	Identical pre & post knowledge test. Follow-up testing scheduled in 12 months.	OSCE practical assessment.	X	X	X
Lindgaard [52] 2017	X	X	Short practical assessment.	25 specific US exams (video sequences & screen shots) uploaded for instructor review.	X	X
Mandavia [67] 2000	X	Identical knowledge assessment pre & post course & at 10 month follow-up (24 positive, negative, & nondiagnostic US images for interpretation).	X	Expert review of trainee images- sensitivity & specificity.	Frequency & application of PoCUS.	X
Nathan [49] 2017	X	Written exam at end of 2 week course for pilot eligibility. Monthly practical assessment for 3 months.	Practical exam at end of 2 week course for pilot eligibility.	Expert review of trainee images for errors in scanning parameters & diagnosis, using predetermined criteria.	X	Patient outcome- High risk pregnancies.
Rominger[24] 2018	Pre-training needs assessment.	X	X	Case logs & images (35%) reviewed for quality assurance & feedback.	Frequency & application of PoCUS following training. Scanning frequency over time.	PoCUS impact on patient management & diagnosis.
Shah [45] 2020	Pre & post US confidence survey & at 3 month follow-up. Key informant interviews assessed trainees’ perception of training program.	X	25 proctored scans prior to final OSCE (80% pass mark).	2 months of blinded expert image review & inter-rater reliability of trainee scans.	X	X
Shah [48] 2014	Post course confidence survey	Pre and post course knowledge assessment.	Time & accuracy of scanning recorded during practical training.	X	X	X
Shah [47] 2009	Pre-training needs assessment.	X	X	Expert review of trainee images for quality & accuracy of interpretation.	X	PoCUS directed change of patient management.
Shah [46] 2008	Pre-training needs assessment. Focus group discussion of barriers to US utilisation.	X	X	X	X	X
Shaw-Battista [29] 2015	Post course evaluation immediately following practical training.	Pre & post online module knowledge test. Passing grade required before seminar & practical training. Post-practical training knowledge test (results not reported).	X	X	X	X
Shokoohi [51] 2019	Post training survey to evaluate course, trainee demographics, medical/PoCUS experience, US use, challenges/barriers & opinions.	X	X	X	Frequency & application of US (including teaching others)	X
Stolz [30] 2015	X	Invigilated examinations conducted throughout 2 year training period.	Invigilated examinations conducted throughout 2 year training period.	X	Frequency & application of PoCUS over duration of training course.	Patient outcome following PoCUS.
Swanson [85] 2014	X	Oral competency tests on return to clinic following training.	Practical competency tests on return to clinic following training.	Expert review of trainee images- Sensitivity & specificity for clinical indications.	X	Patient outcome/ Altered diagnosis following trainee PoCUS.
Vinayak [63] 2017	Patient survey of experience following trainee provided PoCUS.	Pre-test following e-module. Pass mark 100% within 5 attempts to progress to practical training. Post course written assessment.	Practical assessment throughout the course. Post course practical assessment.	Expert review of trainee images for quality & accuracy of interpretation.	Time to complete PoCUS & improvement with time.	Patient outcomes (high risk pregnancies) following Trainee PoCUS.
Vyas [70] 2018	X	X	Post-training OSCE practical assessment.	Blinded expert review of trainee images over following 12 months for image quality ability to identify OB pathology.	X	Patient outcomes.
Wanjiku [21] 2018	3 month post course evaluation.	Online test following self-directed online course- 90% pass mark for eligibility for 1 day practical training. Post course practical assessment.	Post course OSCE/practical assessment with image quality scores. Follow-up in-facility testing scheduled 3–4 months after initial training.	X	Frequency & application of PoCUS following training.	X
Westerway [50] 2019	Course evaluation- satisfaction, engagement, understanding & relevance of learning.	Identical pre & post course knowledge test repeated at 6 & 11 months follow-up.	Post training practical assessment, repeated at 6 & 11 month follow-up.	X	Scanning on returning to clinic/work (confidence and application).	X
Abbreviations *KEF – Kirkpatrick Evaluation Framework OSCE- Objective Structured Clinical Examination PoCUS- Point-of-Care UltrasoundUS- Ultrasound

Figure 3. Kirkpatrick evaluation level reached by the reviewed studies.

Table A1. Search strategy

	Search terms 1 Pregnancy/Antenatal	Search terms 2 Ultrasound	Search term 3 Point-of-Care/Bedside	Search terms 4 Education/Training
MEDLINEMESH HEADINGS	Obstetrics/ Pregnancy/ Prenatal care/ Prenatal diagnosis/ Pregnancy complications/ Pregnancy outcome/	Ultrasound/ Ultrasonography/ Prenatal/ Echography/ Diagnostic imaging/	Point of care systems/	Education/ Clinical education/ Continuing education/ Education program/ Health education/ Medical education/ Nursing education/ Postgraduate education/ Allied health education/ idwifery education/ Outcome of education/	Nurse midwifery education/ Continuing education provider/ Training/ Simulation training/ Staff training/ High fidelity simulation training/ In service training/ Evaluation study/ Program evaluation/ Teaching/
EMBASE MESH HEADINGS	Obstetrics/ Pregnancy/ Pregnancy complications/ Pregnancy outcome/	Ultrasound/ Echography/ Diagnostic imaging/	Point-of-care testing/	Education/ Clinical education/ Continuing Education/ Education program/ Health Education/ Medical education/ Nursing education/ Postgraduate education/ Allied health education/ idwifery education/Outcome of education/	Nurse midwifery education/ Continuing education provider/ Training/ Simulation training/ Staff training/ High fidelity simulation training/ In service training/ Evaluation study/ Program evaluation/ Teaching/
KEYWORDS	Perinatal Prenatal Antenatal Pregn* (Pregnant, Pregnancy, Pregnancies) Obstetr* (Obstetric, Obstetrics, Obstetrician)	Ultraso* (Ultrasound, Ultrasonography, Ultrasonic)	‘Point of care’ ‘Point-of-care’ POCUS Bedside	Evaluat* (Evaluation, evaluating, evaluate) Educat* (Education, Educational, Educate, Educating) Train* (Train, Training, Trainer, Trainee) Workshop* (Workshop, Workshops) Skill* (Skill, Skills)
SEARCH STRING EMBASE	Obstetrics/ or Pregnancy/ or Pregnancy complications/ or Pregnancy outcome/ AND (Perinatal or Prenatal or Antenatal or Pregn* or Obstetr*).mp AND Ultrasound/ or Echography/ or Diagnostic imaging/ AND (Ultraso*).mp AND Point-of-care systems/ AND (‘Point of care’ or ‘Point-of-care’ or POCUS or Bedside).mp AND Education/ or Clinical education/ or Continuing education/ or Education program/ or Health education/ or Medical education/ or Nursing education/ or Postgraduate education/ or Allied health education/ midwifery education/ or Outcome of education/or Nurse midwifery education/ or Continuing education provider/ or Training/ or Simulation training/ or Staff training/ or High fidelity simulation training/ or In service training/ or Evaluation study/ or Program evaluation/ or Teaching/ AND (Evaluat* or Educat* or Train* or Workshop* or Skill*).mp
SEARCH STRING MEDLINE	Obstetrics/ or Pregnancy/ or Prenatal care/ or Prenatal diagnosis/ or Pregnancy complications/ or Pregnancy outcome/ AND (Perinatal or Prenatal or Antenatal or Pregn* or Obstetr*).mp AND Ultrasound/ or Ultrasonography, Prenatal/ or Echography/ or Diagnostic imaging/ AND (Ultraso*).mp AND Point-of-care testing/ AND (‘Point of care’ or ‘Point-of-care’ or POCUS or Bedside).mp AND Education/ or Clinical education/ or Continuing education/ or Education program/ or Health education/ or Medical education/ or Nursing education/ or Postgraduate education/ or Allied health education/ midwifery education/ or Outcome of education/or Nurse midwifery education/ or Continuing education provider/ or Training/ or Simulation training/ or Staff training/ or High fidelity simulation training/ or In service training/ or Evaluation study/ or Program evaluation/ or Teaching/ AND (Evaluat* or Educat* or Train* or Workshop* or Skill*).mp
SEARCH TERMS GOOGLE SCHOLAR	Antenatal OR obstetric AND PoCUS OR ‘Point of care ultrasound’ OR ultrasound AND training OR education
LIMIT	No limit to

Table A2. Modified Medical Education Research Study Quality Instrument (MERSQI) [41,42]

Domain	MERSQI Item	Item Score	Max Score
Study design	Single group cross‐sectional or single group post-test only	1	3
	Single group pre-test & post-test	1.5
	Nonrandomized, 2 groups	2
	Randomized controlled trial	3
Sampling	†Number of Institutions:		3
	1	0.5
	2	1
	3	1.5
	*Number of trainee/learners
	1–10	0.5
	11–50	1
	51+	1.5
*Follow-up of training	Not performed	0	3
	Post training/ongoing support	1
	Follow-up assessment- retention of learning	2
	Follow-up/refresher training	3
Type of data	Assessment by participants	1	3
	Objective measurement	3
Validity assessment of evaluation instrument	Internal structure:		3
	Not applicable
	Not reported	0
	Reported	1
	Content:
	Not applicable
	Not reported	0
	Reported	1
	Relationships to other variables:
	Not applicable
	Not reported	0
	Reported	1
Data analysis	Appropriateness of analysis:		3
	Inappropriate for study design or type of data	0
	Appropriate for study design, type of data	1
	Complexity of analysis:
	Descriptive analysis only	1
	Beyond descriptive analysis	2
Outcomes	Satisfaction, attitudes, perceptions, opinions, general facts	1	3
	Knowledge, skills	1.5
	Behaviours	2
	Patient/health care outcome	3
Total possible score			21

Adapted from the Medical Education Research Study Quality Instrument (MERSQI) [41,42]. *Categories added- Number of trainees (score of 0.5 to 1.5); Follow-up of training (score of 0 to 3).Categories omitted- Response rate (%). Possible score range from 5 to 21 (original MERSQI instrument 5 to 18).

Table A3. Risk of bias assessment tool [72]^.

Note- ‘Poor/limited reporting’ increases the risk of bias and does not necessarily mean the educational development is of poor quality. Low quality limits utility for readers in determining transferability of the educational development [72].

Table A4. Training methods and delivery

First author Year Published Location Rural / Urban Income classification	Training duration & delivery	Trainees (Number, role/discipline, previous US experience)	Instructors (Qualification of instructor/s & ratio of instructor to trainees)	Curriculum Course topics & Practical skills taught (Obstetric only or multiple organs systems)	Follow-up training & support (Refresher training, follow-up assessment, distance or online support & mentoring provided/offered)
Adler [66] 2008 Africa, Tanzania (refugee camp) Rural LMIC	4 days- Morning lectures followed by afternoon practical.	Multidisciplinary 10 trainees- 4 Physicians, 6 Clinical officers. US experience not specified/unclear.	Instructor credentials and group sizes not specified.	Multiple systems- Basic US physics, knobology, & reviews of clinical US including: US evaluation of 1^st trimester pregnancy; Pregnancy dating & fetal position; FAST; US evaluation of the abdominal aorta; Hepatobiliary US; US-guided procedures; Soft tissue US; Basic echocardiography; Renal US.	Follow-up at 2 years- 1 instructional session to reinforce prior learning.
Baltarowich [61] 2009 Africa- Sub-Saharan (Training conducted in USA) LIC/LMIC	3 months- didactic lectures, case review sessions, informal teaching sessions, conferences, hands-on sessions using a variety of equipment, & clinical observation rotations.	12 Physicians- 11 radiologists, 1 intern.US experience- 2 to 20+ years.	Training groups of 6. 1:6	Multiple systems- Focus on OBs with In-depth training in: US physics, instrumentation, cross-sectional anatomy, abdomen, OB/GYN. Overview of diagnostic US in the areas of vascular, echocardiography, musculoskeletal, paediatrics, thyroid, prostate, sonomammography, & interventional techniques. Care & maintenance of US equipment, preparation techniques for effective teaching.	Follow-up written test after 6 months, 8/12 trainees returned for a 4 week update program at 12 months.
Bell [22] 2016 Africa, Kenya Rural LMIC	1 day & 1–2 follow-up sessions offered every 3–5 months for 1 year.	Multidisciplinary 81 trainees- Equal proportion of doctors, nurses & clinical officers. Several sonographers & 1 lab assistant. Most with no US experience.	US credentialed EM physicians. 4–5 trainees in practical sessions. Ratio 1:4–5	Multiple systems- Physics & machine use; OB exam for intrauterine pregnancy, cul-de-sac fluid, FH activity & position; The abdominal, pleural & cardiac assessment for free fluid; The thoracic exam for pneumothorax.	1–2 follow-up refresher sessions offered at 3 to 5 months.
Dalmacion [25] 2018 Asia, Philippines Rural & urban study sites LMIC	2–3 days- Classroom lectures & hands-on training. 2–3 days scanning pregnant women recruited by the study.	Multidisciplinary 20 trainees- 6 doctors, 9 midwives, 5 nurses. US experience not specified/unclear.	Credentialed OB sonographers. All lectures delivered by team leader.	Obstetrics only- Trained to identify & measure 5 OB US images- 1. Viability of the fetus 2. Number of pregnancies 3. Fetal presentation 4. Placental location 5. Amniotic fluid volume (AFV) using maximal vertical pocket	*NR
Dornhofer [54] 2020 Indonesia, East Java Urban UMIC	4 weeks- 6 sessions (3–4 days apart), 6 hours of lectures & 18 hours of practical.	Multidisciplinary 51 Trainees- 19 physicians, 19 midwives, 13 nurses. 36 (65%) had no prior US exposure, 40 (73%) observed US in practice, 4 (7%) attended prior US course.	8 Medical students- 1st year of medical education completed including- lectures on PoCUS for 8 organ systems & 10 hours of supervised hands-on training per organ system, assessment using healthy volunteers. Ratio 1:4 or 1:5 for hands-on training, 2 medical student instructors per US machine/station to 10 trainees.	Multiple systems- 6 session, 1 OB/GYN focussed 1. Basic US including US physics, machine knobology, probe manipulation, & scanning techniques. 2. Pulmonary US, evaluation of pneumothorax, pleural effusions, & pneumonia. 3. Cardiac US in the parasternal long axis view, parasternal short axis view, apical four chamber view, & subxiphoid view. 4. Abdominal US- hepatic, biliary, renal, intestinal, aorta, & inferior vena cava. 5. OB/GYN US including identification of intrauterine pregnancy, estimated GA, visualization of the ovaries, & bladder. 6. Combination of previous sessions to aid FAST & the Focused Assessment with Sonography for HIV-Associated Tuberculosis (FASH).	*NR
Henwood [53] 2017 Africa, Rwanda Rural LIC	10-day course. 6 months scanning assessment for image accuracy.	17 Physicians- US experience not specified/unclear.	EM physicians with expertise in PoCUS, consultant obstetricians & radiologists.	Multiple systems- Introduction to PoCUS & common applications. OBs- Gestational sac, Yolk sac, Fetal pole, FHR, Endomyometrial mantle, CRL, BPD, FL, Fetal lie, placental location, Placenta previa, Hydramnios. Echocardiography, Abdominal, Lung, Spleen, Liver, Biliary, Renal, Soft tissue.	Follow-up training every 6 weeks for 6 months trial period with regular practical assessments. Onsite image review & technical assistance.
Kimberly [62] 2010 Africa, Zambia Rural LMIC	6 months- 3 training periods of 2 to 3 weeks interspersed by 2 to 3 months of independent scanning under minimal supervision	21 Midwives- No prior US experience.	3 emergency US fellowship trained physicians.	Obstetrics only- US machine use, cleaning & storage, Patient data entry, image saving (for review), & exam datasheet completion. Practical- Identify basic OB applications: Fetal presentation (vertex or breach), FHR (presence & use of callipers to calculate the rate), Placental location (anterior, posterior, low-lying, or previa), number of gestations & GA based on BPD & FL.	1 year follow-up visit questionnaire of PoCUS application & frequency, no additional training.
Kolbe [26] 2015 Central America, Nicaragua Rural & urban study sites LMIC	Daily morning didactic sessions & practical workshops, afternoon US of patients from the community (course duration unclear), followed by 3 months remote guidance & telecommunication.	Multidisciplinary 4 trainees- 2 postgraduate rural medicine physicians, 1 nurse, 1 nursing assistant. US experience not specified/unclear.	Experienced international sonographers. Ratio 1:4.	Multiple systems- OBs- Normal pregnancy, Fetal viability; Complicated pregnancy (Ectopic pregnancy, Placenta previa, Placenta abruption). Other systems- Echocardiography, Hemodynamic evaluation, Pleural, Lung, Abdominal & Vascular US.	Weekly 60–90 min remote guidance sessions & telecommunication supportfor 3 months following training.
Kotagal [56] 2015 USA, Washington Urban aimed at rural deployment HIC	14 hours- 7 sessions of 2 hours over 3 months.	16 General surgery residents-Limited previous US training (guidance for central venous catheter placement & a brief FAST training).	Multidisciplinary faculty (Surgery, Radiology, Anaesthetics & EM) with expertise in PoCUS.	Multiple systems- Topics- US physics, knobology, safety & artifacts; FAST; Skin & soft tissue US; OB US (early & late pregnancy); Focused echocardiography & volume assessment; Procedural guidance US (paracentesis, thoracentesis, & pericardiocentesis); Vascular US (abdominal aorta & deep vein thrombosis); US guided regional anaesthesia.	*NR
Lathrop [58] 2011 USA, Indianapolis Urban HIC	Half day workshop- 45 minute instruction session followed by practical.	4 Advanced practice Nurses (APN)- 3 attended previous didactic US training.	Credentialed US provider. Ratio 1: 2–3 for practical workstations.	Obstetric Only- Instruction session (45 mins)- Review US standards of care, basic review of US physics & instrumentation, indications, clinical significance & documentation. Practical session- Fetal number, demonstration of life, estimate amniotic fluid, placenta location & fetal presentation. Learning portfolio- (a) documentation of didactic learning (certificates from US-related training or workshops attended); (b) readings (journal articles, clinical bulletins, & practice statements); (c) US cases.	No follow-up of trainees reported but an additional future workshop planned to include more advanced skills, such as fetal biometry, first-trimester US, & cervical length measurement.
Lee [55] 2017 Indonesia, Bandung Urban UMIC	4 weeks – 6 sessions. Each session- 30 min lecture followed by 2 hours hands-on training.	41 Physicians- 22 (53.7%) no prior US experience, 18 (43.9%) observed US in practice, 1 (2.4%) attended prior US course.	Medical students- 1st year of medical education completed including- lectures on PoCUS for 8 organ systems & 10 hours of supervised hands-on training per organ system, assessment using healthy volunteers.	Multiple systems- 6 sessions, 38 US milestones. 1- Basic US including physics, knobology, probe manipulation & scanning techniques. 2- Pulmonary US, evaluation of pneumothorax, pleural effusions & pneumonia. 3- Cardiac US in the parasternal long axis view, parasternal short axis view, apical four chamber view & subxiphoid view. 4- abdominal US (hepatic, biliary, renal, intestinal, aorta & inferior vena cava). 5- OB/GYN US (identification of intrauterine pregnancy, estimated GA, visualization of the ovaries & bladder). 6- combination of previous sessions to aid FAST & the Focused Assessment with Sonography for HIV-Associated Tuberculosis (FASH).	Follow-up scheduled for 12 months to re-test trainees & assess use of US.
Lindgaard [52] 2017 Denmark, Odense Urban HIC	2 days practical & feedback session following online learning package.	5 General Practitioners- 4 specialist GPs, 1 final year resident. No formal US training.	Instructors from Center of Clinical US, University of Aarhus.	Multiple systems- E-learning online lectures- Basic US knowledge- physics & US equipment; Focused US examinations of thoracic structures, abdomen, vascular & musculoskeletal. Practical exams conducted- Intrauterine pregnancy; GA; Gall-stones; Ascites; Abdominal aorta.	*NR
Mandavia [67] 2000 USA, California Urban HIC	16 hours over 2 days. 8 hours lectures & 8 hours practical.	Multidisciplinary 80 trainees- 16 attending physicians, 53 ED house officers, 4 physician assistants, 7 medical students. Prior US training experience- none (58), minimal 1–5hrs (6), moderate 5–10 hrs (9), & extensive >10 hrs (7).	Board-certified US trained EM physicians & certified registered diagnostic medical sonographers. Ratio 4:1 per US/station for hands-on learning.	Multiple systems- Curriculum based on Society for Academic Emergency Medicine guidelines. Lectures- Basic physics; Pelvis & OB; Right upper quadrant; Renal; Aorta; Trauma; Echocardiography. Practical- OB skills included: Detection of early intrauterine pregnancy &/or free pelvic fluid; Detection of live fetus in 2^nd/3^rd trimesters.	Follow-up identical test at 10 months & images performed over this time reviewed for accuracy.
Nathan [49] 2017 5 sites: Democratic Republic of Congo, Karawa Guatemala, Chimaltenango Kenya, Eldoret Pakistan, KarachI Zambia, Lusaka Rural LIC/LMIC/UMIC	2 weeks- One third didactic sessions, two thirds practical scanning. 2 supervised US exams on each day of the course.	Multidisciplinary 41 Trainees- 10 medical officers, 18 nurses, 6 midwives, 7 radiographers. No prior US experience.	Training under the direction of a Radiologist. Local sonographer for ongoing training, QA & trainee evaluation. Image review by: Radiologist (25 yrs in OB US), 2 professors of OBs; a professor of radiology (10 yrs in OB US); & 2 lead OB sonographers.Training groups of 4 to 12 – ratio not specified.	Obstetric only- Curriculum development- Didactic & hands-on instruction, printed materials, extensive quality assurance activities, educational outreach visits, daily schedule, speaker notes for PowerPoint slides, & explicit instructions for each practical scanning session. Topics- Patient communication, safety, & comfort; Infection prevention & control; Care & security of the equipment; US physics & instrumentation; Anatomic planes & introduction to tomography. Practical skills- Detection of cardiac activity; Fetal number, Fetal position, Amniotic fluid assessment; BPD; HC; AC; FL; Placental position; Cervical length at 16–24 weeks; Detection of some anomalies (ventriculomegaly, anencephaly, hydronephrosis, & spina bifida).	For the 12 week pilot period- Monthly follow-up & practical assessment. Local instructors met trainees to discuss performance & observe scanning progress bi-weekly. Image feedback from quality control website. Targeted remedial training given to some trainees.
Rominger [24] 2018 Mexico, Chiapas Rural UMIC	16 days training over 12 month duration. Total of 4 sessions (each session 4 day course) every 3–4 months.	10 Physicians-Little to no prior US experience.	Obstetrician, Paediatric EM physician, EM physician & residents. 6 to 10 trainees per 2 instructors. Ratio 1:3–5	Multiple systems- 1- Introduction to US, equipment use & care, FAST, kidney & bladder evaluation, basic OBs. 2- Lung, skin & soft tissue, & musculoskeletal US. 3- OB/GYN physician taught focused on OBs. 4- Review of US basics, cardiovascular, advanced abdomen, & ocular.	Case logs & images (35%) reviewed for quality assurance & feedback.
Shah [45] 2020 Africa, Uganda LIC	2 days intensive training course followed supervised (Master trainer) scanning 2–3 days per week for 3 weeks.	Multidisciplinary 25 Trainees- 20 midwives, 3 nurses, 2 physicians. No prior US experience.	Certified sonographer, OB/GYN resident physician, family physician & 3 EM physicians with US training. Instructors had prior experience in PoCUS in LMIC. Ratio 1:3 for practical scanning.	Obstetrics only- Short lectures & hands-on demonstrations using healthy volunteers, hands-on live scanning practice on 3^rd trimester antenatal patients not in labor, & mock active labor patients. Topics- US knobs & Physics; US Safety; Principles of adult learning; US teaching methods; Hands-on training techniques; Fetal position; Placental position; Fluid volume; Multiple gestation; FHR; Estimating GA: BPD, HC, FL, TCD; Common learner mistakes.	Twice weekly distance/online communication for 3 months.Confidence survey repeated at 3 months. Key informant interviews assessed trainee’ perception of training program
Shah [48] 2014 USA, North-western Urban HIC	3 hours- 1 hour lecture, 2 hours practical.	31 Emergency physicians- 17 attendings, 14 residents. Range of no prior experience to experienced.	US fellowship trained EM physicians. 1:1 for hands-on instruction.	Obstetric only- Mechanics of TA & TV US. General review of 1st trimester US including- Normal US findings in 1st trimester, Other abnormal US findings in early pregnancy (fetal demise, molar pregnancy), finding FHR using M-mode, measurement of GA using CRL, & ectopic pregnancy. Late pregnancy US including fetal lie & identification of the fetal head, & fetal biometry including measurement of BPD, FL, HC & AC. Practical- live models in the 2nd & 3rd trimester of pregnancy.	*NR
Shah [47] 2009 Africa, Rwanda Kirehe & Rwinkwavu in Eastern Province Rural LIC	9 weeks- 1 hour lecture (15 lectures total) followed by 1–2 hours practical.	10 Physicians-Little to no prior US experience.	US training sessions conducted by a 4th year EM resident with prior US experience (including OB US) during residency training & credentialing certification.	Multiple systems- Principles of US physics; Machine operation; Potential uses of US; Outline of lecture series, training expectations, image & data sheet recording instructions. OB US including 1^st trimester basics- ectopic or molar pregnancy, estimating GA, & evaluation of fetal position, cervix & placenta. Cardiac US; Hepato-biliary US; Renal US; Advanced applications- US evaluation of DVT, procedures including vascular access, abscess evaluation & drainage, US guided paracentesis & thoracentesis.	Image accuracy & quality assessed by expert review. Telecommunication (email) support offered.
Shah [46] 2008 Africa, Rwanda, Kirehe & Rwinkwavu in Eastern Province Rural LIC	9 weeks- 1 hour lecture (15 lectures total) followed by 1–2 hours practical.	15 physicians- 0–4 h of prior US training solely in OBs.	US training sessions conducted by a 4th year EM resident with prior US experience (including OB US) during residency training & credentialing certification. Cardiac echo lecture given by visiting Cardiologist.1:1 for scanning practice during ward rounds. Other group sizes not specified.	Multiple systems- Principles of US physics; Machine operation; Potential uses of US; Outline of lecture series, training expectations, image & data sheet recording instructions. OB US including 1^st trimester basics- ectopic or molar pregnancy, estimating GA, & evaluation of fetal position, cervix & placenta. Cardiac US; Hepato-biliary US; Renal US; Advanced applications- US evaluation of DVT, procedures including vascular access, abscess evaluation & drainage, US guided paracentesis & thoracentesis.	Image accuracy & quality to be assessed by expert review (Shah 2009). Telecommunication (email) support offered.
Shaw-Battista [29] 2015 USA, California Urban HIC	10 asynchronous online modules followed by 4 hours training- 2 hour seminar, 2 hour practical.	Multidisciplinary Initial course- 72 trainees- Midwives, nurses, family practice physicians, physician assistants Developed course- 162 trainees- Midwives, nurses, nurse practitioners, medical & midwifery students, family practice & OB physicians, physician assistants. Range of no prior US experience to experienced.	Senior OB & family medicine residents (advanced trainees & licensed clinicians).Ratio 1:3–5 during practical sessions.	Obstetrics only- Asynchronous online module topics- Indications for OB US; Documentation, communication, liability, & risk-reduction strategies; US physics, equipment, & optimizing image quality; Normal 1st trimester US; Abnormal 1st trimester US; Limited 2nd & 3rd trimester US; Fetal biophysical profile; 2nd & 3rd trimester fetal biometrics; Use of OB US on the labor & delivery ward; Interprofessional OB US training & practice.	*NR
Shokoohi [51] 2019 Africa, Tanzania, Malawi & Uganda Rural & urban LIC/LMIC	2 day training course. Online modules & educational materials provided.	Multidisciplinary 49 Trainees (initial 63 with 78% response rate)- 7 midwives, 42 physicians (different specialties).21/49 never performed independent US,29/49 limited US training during residency.	Sonographer. Ratio 1:3–4 during course. Ratio 1:1 for in clinic training.	Multiple systems- Topics- review of the concepts for clinician- performed US, introduction to the US machine & controls, the focused assessment with sonography for trauma/focused assessment with sonography for human immunodeficiency virus/tuberculosis (FAST/FASH), abdominal US exam, echocardiography, lung, renal/bladder & abdominal US Midwives & obstetricians received focused training on gynaecologic US & 1^st & 3^rd trimester US.	Telecommunication support- Online feedback on transmitted images from independent scanning after training
Stolz [30] 2015 Africa, Uganda LIC	2 years- US lectures delivered intermittently over the 2-year ‘emergency care for non-physicians’ curriculum (train the trainer model) with the core US lectures occurring early in the programme.	13 Nurses-US experience not specified/unclear.	EM physicians with fellowship training in emergency US or strong clinical competency in emergency US.	Multiple systems- 1. Introduction to PoCUS, Machine care, basic physics & US principles, image optimisation, knobology, safety, patient consent & documentation in the medical record. 2. FAST; 3. Echocardiography; 4. Hepatobiliary US; 5. Renal US; 6. Soft tissue US; 7. Lung US; 8. Aorta US; 9. Inferior vena cava US; 10. OB/GYN US- Evaluation of intrauterine pregnancy, signs of ectopic pregnancy, pelvic free fluid, adnexal mass, foetal heart rate, foetal movement, fetal dating & fetal presentation 11. Abdominal US; 12. Procedural guidance with US; 13. US assessment for deep vein thrombosis.	*NR
Swanson [85] 2014 Africa-Uganda Rural LIC	6 weeks- Lectures, small-group tutorials, audio-visual materials & supervised clinical scanning.	14 midwives- 13 no prior US experience, 1 experienced.	Primary instructors’ credentials not specified. Sonographer for ongoing scanning support.	Obstetric only- Curriculum included US physics, relevant anatomy & physiology, instrumentation & basic maintenance. Screening included- cardiac activity (yes, no), fetal presentation (cephalic, breech & others) & fetal number, Placental position (normal, previa & low lying), Pain & bleeding (complete abortion, incomplete abortion, blighted ovum, ectopic pregnancy or placental abnormality).	Ongoing training resource in onsite sonographer available to trainees on return to clinic
Vinayak [63] 2017 Africa, Kenya Outer regional & Rural LMIC	4 weeks- 1 hour lecture, 6 hours practical, 1 hour feedback & debrief per day (days per week unclear). Several days of assessment after course completion.	3 midwives- No prior US experience.	‘Experienced sonographers. Ratio 1:3.	Obstetrics only- 1. E-learning module- introduction to general principles of US, US physics & OB US. 2. Post module test 3. Didactic lectures- US knobology, general & OB US 4. Hands-on practical experience. Practical skills- HC, AC, FL & FHR & rhythm. Placenta location & distance of lower lip from the cervix & estimated the amount of amniotic fluid (obtained from four images, one image for each quadrant).	*NR
Vyas [70] 2018 America, Panama (Training in USA) Rural HIC	12 hours- 6 sessions on OB US instruction, termed “Rural Obstetric Ultrasound Triage Exam” (ROUTE).	8 medical students- Prior basic US training in medical school curriculum.	Trainer- 3rd year OB/GYN resident physician. Assessment by board certified OB/GYN physicians.	Obstetric only- ROUTE including identification of- fetal lie, placental position, DVP, amniotic fluid index (AFI), BPD, & HC for 2nd & 3rd trimester.	*NR
Wanjiku [21] 2018 Africa, Kenya Rural LMIC	1 day practical training following self-directed online pre-training.	Multidisciplinary 33 trainees- Clinical officers, Nurses, Medical officers. All had previously completed a novel pilot PoCUS training program. Other prior US training excluded participation.	Certified Instructors.	Multiple systems- Standardized OSCE trainees assessed on – FAST (Trauma assessment), 1^st & 2^nd/3^rd trimester scanning skills, i.e., identification of the gestational sac, 1^st trimester dating using crown-rump length, detecting & measuring the FHR, identifying the presenting part, locating the placenta, & measurement of HC & BPD.	Follow-up in-facility testing scheduled 3–4 months after initial training. 3–4 month refresher training offered to trainees who failed practical assessment.
Westerway [50] 2019 Australia Rural & urban HIC Indonesia/Central Asia/Timor Leste UMIC/LMIC	6 separate PoCUS courses compared. Ranging from 4 to 18 hours total. Up to 6 hours lecture, 3–12 hours practical.	Multidisciplinary 55 trainees- 15 medical practitioners, 23 midwives, 9 nurses, 8 radiographers. No prior US experience.	Experienced OB US tutors. Same lead lecturer for all 6 courses. Ratio from 1: 2–5 (average 1:4).	Obstetric only- Curriculum- Clinical history- pregnancy progression; Knobology, image optimisation (depth, focus, gain) & probe use; Theory behind performing a limited fetal anatomical assessment & 3rd trimester fetal biometry. Practical checklist- Image optimisation; Probe movements; Fetal lie; FHR; Recognition of fetal anatomy (heart, stomach & bladder); Amniotic fluid estimate (single deepest pocket); Identification of cervix & placental position; Fetal biometry measurements (BPD, HC, AC, FL).	Follow-up test & practical at 6 & 11 months
Key- *NR = not reported/described
Abbreviations AC – Abdominal Circumference AFV – Amniotic fluid volume BPD – Biparietal Diameter CRL – Crown to Rump Length DVP – Deepest Vertical Pocket ED – Emergency Department EGA – Estimated Gestational Age EM – Emergency Medicine FAST – Focused Assessment with Sonography in Trauma		FH – Fetal Heart FHR – Fetal Heart Rate FL – Femur Length GA – Gestational Age HC – Head Circumference HIC – High-income country LIC – Low-income country LMIC – Lower-middle-income country LRS – Low-resource setting		OB – Obstetric OB/GYN – Obstetrics and Gynaecology OSCE – Objective Structured Clinical Examination TA – Transabdominal TCD – Trans Cerebellar Diameter TV – Transvaginal UMIC – Upper-middle-income country US – Ultrasound

Table A5. Quality assessment and bias ranking of included articles using a modified Medical Education Research Study Quality Instrument (MERSQI) [41,42]

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Data availability statement

Additional data referred to but not included in the main manuscript is provided in the Appendix as supplementary material (‘Additional Tables’).