Shaping ultrasound in midwifery: towards an evidence-based training framework for enhanced prenatal care

Background Academic advancement of the midwifery profession highlights the need to establish standardized qualifications in obstetric ultrasound diagnosis, being a central part of prenatal care. Thus, introduction of an evidence-based training program is warranted. We aimed to reviewed curriculum designs used in midwifery ultrasound education. Methods A systematic literature research was conducted. Embase, PubMed and Google Scholar database was reviewed for publications using the terms “[midwife], [midwives], [midwifery students], [obstetric ultrasound], [midwife sonographer] and [education], [teaching], [program], [course], [curriculum] and [learning]”. Papers with full description of curriculum designs or educational programs on obstetrical ultrasound for midwives were included and scrutinized against pre-defined criteria according to the PICO (Population, Intervention, Comparator, Outcomes) scheme. Results 29 publications were included. Studies demonstrated a significant disparity according to course concepts being used. Differing parameters included: Duration, structure, learning approaches, course content, examination concepts and target groups (practising midwives vs. midwives in education). Conclusion An evidence-based ultrasound educational program for midwives remains to be developed, including further educational guidelines. Clinical applications by midwives, as well as the distinctions from medical practise, particularly in terms of legal considerations, needs to be defined.


Introduction
Increased sophistication in ultrasound technologies has enabled ultrasonographic diagnostics becoming an essential part in pregnancy care.From the initial focus on screening programs and evaluation of fetal and placental assessment, published studies had further demonstrated the feasibility and utility of ultrasound diagnostics during the intra-and postpartum course [1][2][3][4][5][6].
Given the continuous increase in out-of-hospital births, which are amongst others home births, or births in midwifeled institutions corresponding to independent births centres, the utilization of ante-and intrapartum ultrasound technology by midwives has the potential to decrease intra-and postpartum complications [7,8].In consequence, ability by midwives to promptly identify and evaluate potential risks, facilitates a timely hospital transfer, thus enhancing maternal and neonatal outcomes.
The regular incorporation of ultrasound into midwifery practise becomes achievable by the growing availability of point-of-care ultrasound devices.The use of small and handy devices, possess midwives the flexibility to perform examinations in direct patient contact and regardless of where they are needed [9][10][11].
Within the context of the ongoing academization of the midwifery profession, one of the primary objectives is the qualitative and competence-enhancing further development of midwifery.This includes adapting to new opportunities in diagnostics and preventive measures, made possible by the medical progress [9][10][11].Hence, innovative practices, such as ultrasound, can enhance the midwife's prescribed activities, presenting valuable opportunities to progress towards a comprehensive ante-, intra-and postpartum obstetric care.
However, as the level of expertise mainly determines for an adequate reproducibility and for a correct interpretation of data, evidence-based training programs are needed.We aimed to present the current state of obstetric ultrasound education for midwives in the context of introducing an evidence-based German training program.For this, we performed a systematic literature review and compared previous published data, regarding different didactic methods, course contents (incl.ante-, intra-and postpartum ultrasound), learning approaches, examination concepts, target groups (practising midwives vs. midwives in education), course durations and course formats.Current developments and challenges arising by the ongoing process of academization and the draft amendment of the Midwifery Act were further discussed.

Search strategy
In the process of conducting the systematic literature search, the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting systematic reviews and meta-analyses of studies was followed (Fig. 1) [12,13].
In April 2023, the PubMed, Embase and Google Scholar databases were searched for relevant publications in English, French or German on the topic of midwifery education in obstetric ultrasound using the keywords [

midwife], [midwives], [midwifery students], [obstetric ultrasound], [midwife sonographer] and [education], [teaching], [program], [course], [curriculum] and
[learning].To formulate a specific search query, keywords were partially linked with operators as follows: "obstetric ultrasound", "midwifery education programs", "midwife sonographer", "midwifery students", allintitle: midwives obstetric ultrasound.Titles and abstracts were screened by three authors in an unblinded manner for compliance with inclusion criteria.Hence, relevant study characteristics had been specified in advance using the PICO (Participants, Intervention, Comparator, Outcomes) process (Table 1) [12].A comprehensive systematic review was conducted on the corpus of literature pertaining to the instruction of midwives in the domain of obstetric ultrasound.The inclusion criteria were broad, encompassing retrospective and prospective research studies, surveys, clinical guidelines, professional recommendations, and other scholarly works that addressed aspects of midwife education in obstetric ultrasound.Specifically, the review focused on literature detailing the educational levels of midwives, their learning objectives, curriculum design and structure, pedagogical strategies, instructional materials, methods of assessment, challenges encountered in previous implementations, potential opportunities for advancement, and solutions, as well as the incorporation and utility of specialized ultrasound technology and instrumentation, where applicable.The selection process did not discriminate based on the disciplinary backgrounds of the authors.Exclusions were made for articles not written in German, French, or English, duplicates, those divergent in theme, and any without accessible full-text versions.For the purpose of data extraction, three researchers (J.G., F.R., and A.W.) conducted a thorough double review of the full texts of all identified sources.The article is structured around key questions, which served as a framework for guiding the systematic extraction and synthesis of data.

Registration
This systematic literature review has been successfully registered to the international prospective register of systematic reviews PROSPERO on 10/7/23 with the registration number: CRD42023440461.

Results
Finally, 29 articles, comprising 4 reports and 25 studies, were acceptable for consideration in the literature selection (see Fig. 1).Tables 2, 3 and 4 list all reports and studies with respect to their PICO criteria and Fig. 2 illustrates the geographical parts of the world from which the included publications originate.

In which stage of education midwives are trained in obstetric ultrasound?
The pedagogical orientation of obstetric ultrasound training programs for midwives is predominantly focused on practitioners with foundational competencies in midwifery, yet devoid of prior ultrasound experience [14,15].It is observed that a significant proportion of midwives engaging in obstetric ultrasound education exhibit minimal baseline proficiency in ultrasonography, often with negligible formal training and lacking routine application in their professional practise [16,17].In terms of clinical experience, a substantial body of research includes midwives with extensive practise in the field of midwifery.For instance, Viner et al. have documented the involvement of midwives possessing credentials in nursing and midwifery, with an average midwifery experience of 10.5 years, albeit without prior exposure to ultrasound technology [14].Conversely, certain educational programs also cater to midwives with considerably less professional experience, such as under five or three years [15,18].
For midwives, participation in continuing education courses on ultrasound diagnostics represents a significant enhancement of their ultrasonographic skills and knowledge,     augmenting their existing clinical competencies [19].
Throughout the duration of these training courses, midwives are either relieved from their clinical responsibilities or they undertake the training concurrently with their standard duties [17,20].Distinct from the prevalent focus of research on training practising midwives in obstetric ultrasound, Gueneuc et al. have highlighted the enrollment of student midwives, specifically those in the concluding stages of their midwifery education, in ultrasound training programs [21].

What intention leads to develop and implement the obstetric ultrasound courses for midwives?
The initiative to develop and implement ultrasound training programs for midwives is predominantly observed in low-and middle-income countries (LMICs) (see Fig. 2), where access to ultrasound services for pregnant women is often limited [14].Geographic challenges, including extensive distances and inadequate transportation infrastructure, compound the difficulty of accessing obstetric care, imposing economic burdens [17].These regions are further characterized by a significant dearth of trained personnel and insufficient resources for hospitalization, alongside deficiencies in antenatal care and elevated rates of maternal and fetal mortality [17,20].In LMICs, congenital anomalies account for approximately 5-7% of perinatal mortality rates, suggesting that improved access to obstetric ultrasound could enhance the detection of highrisk conditions and improve maternal and neonatal outcomes [22,23].
The strategic training of midwives in obstetric ultrasound seeks to mitigate the impact of sonographer shortages.[15] Evaluation of point-of-care ultrasound training for midwives MSc.Thesis 2021 Uys, N. [41] A health systems engineering approach to meeting the demand for skilled foetal ultrasound services in the Boland/Overberg public health district Midwives, given their direct involvement in the care of pregnant women, emerge as the ideal candidates for the acquisition and application of obstetric ultrasound skills, with the primary goals of augmenting clinical care, expediting the management of expectant mothers, and reducing incidences of preventable deaths [22,[24][25][26].
Improving healthcare and ultrasound services in areas with limited resources, WHO recommendations suggest to let trained non-physician providers, to handle specific physician tasks.With antenatal ultrasounds in these areas being performed by midwives, further WHO recommendations like at least one ultrasound scan before 24 weeks of pregnancy might be fulfilled [25,27].
In addition, ultrasonography serves as a more accurate alternative to traditional methods of gestational age estimation, such as abdominal palpation and calculation based on the last menstrual period [25].This non-invasive, cost-effective approach not only enhances the accuracy of physical assessments and clinical decision-making but also facilitates timely referrals to specialized care centers [20,23,24,28].
The introduction of point-of-care ultrasound (POCUS) training programmes addresses the specific needs of patients in rural settings through the use of portable equipment and the capability for bedside examinations.This strategy enables prompt and appropriate prenatal care planning and referrals for urgent cases [20].

Which learning objectives should be achieved at the end of the obstetric ultrasound course?
Within the scholarly literature, there exists a consensus regarding the objectives of basic obstetric ultrasound training for midwives.Such courses are designed to acquaint midwives with the fundamentals of ultrasound technology, including the operational setup of ultrasound machines, maneuvering of the equipment, and generation of high-quality diagnostic images.The curriculum extends to foundational knowledge in ultrasound physics, and an overview of the technology's capabilities and limitations [16,25,28].
A critical component of the training involves fostering effective communication skills and professional conduct during patient interactions, emphasizing the significance of the midwife's role in prenatal ultrasound examination.This aspect of training underscores the importance of patientcentered care and safety [24,25].
The educational objectives also encompass the acquisition of skills necessary for conducting various obstetric ultrasound examinations, with a particular focus on fetal biometry for gestational age estimation.Key biometric indicators include the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), crown-rump length (CRL), and femur length (FL) [16,25,29].In addition, midwives are educated on identifying fetal presentation, vitality, and number, as well as placental positioning and amniotic fluid volume [24].
Participants are trained to perform comprehensive assessments of maternal and fetal anatomy across all trimesters, enabling the identification of both normal and pathological conditions [30].This capability is vital for the early detection of high-risk pregnancies and conditions such as placenta previa, oligohydramnios, or malpresentation, facilitating timely referral to specialized care [29,30].
Furthermore, the curriculum may include elements of interprofessional collaboration, aiming to enhance the participants' comprehension of cooperative healthcare delivery, task delegation, and shared responsibilities.This aspect of training is intended to foster a multidisciplinary approach to patient care, improving outcomes through integrated team efforts [28].

Which educational approaches are currently being explored?
While numerous studies exhibit congruent objectives in the instruction of basic obstetric ultrasound skills to midwives, diverse pedagogical strategies are discernible across the literature (see Fig. 3).A common framework involves a bifurcated approach to teaching, intertwining theoretical knowledge with practical application.Despite variations in the emphasis and allocation of these components across different programs, a predominant focus on hands-on experience is noted.[17,20].
The instructional trajectory typically initiates with didactic sessions, transitioning through a spectrum of educational methodologies that include lectures, case discussions, and live demonstrations [18,23].The incorporation of case-based seminars facilitates the application of theoretical knowledge to real-world scenarios, fostering critical thinking and dialogue [28,31].Course formats vary, with some programs delivering theoretical content in-person, while others explore the efficacy of digital platforms or self-guided study through electronic modules [18,22,24].
Zimmermann et al. highlighted the use of the "Esimgo" e-learning platform, which organizes content into sequentially structured modules, enhancing the practical training phase [32].Similarly, Shaw-Battista et al. utilized asynchronous online modules to accommodate participants from remote locations, underscoring the adaptability of digital learning environments [28].
Practical training, often constituting the majority of the course duration, includes direct interaction with ultrasound equipment and live scans on pregnant volunteers, occasionally supplemented by simulation-based experiences.This phase emphasizes the importance of mentorship, with trainers providing real-time feedback and support [14,28,31,32]: Following practical instruction, a clinical phase enables the application of acquired skills in a professional setting, with ongoing expert supervision and feedback serving as a mechanism for continuous learning and quality assurance.This period, typically ranging from 3 to 6 months, represents a crucial phase of workplace-based learning [14,17,18].
Blended learning approaches, combining digital modules with in-person instruction, offer a flexible foundation for theoretical understanding, subsequently reinforced through practical and clinical experiences [18].Innovative formats, such as live remote guidance during ultrasound sessions and interprofessional courses, highlight the evolving nature of ultrasound education for midwives [27,28].
The duration of these courses varies significantly, from intensive 2 day workshops to multi-week programs, reflecting the diversity in educational design and objectives [23,24,26].Support mechanisms, including online forums and diagnostic flowcharts, provide additional resources, facilitating a comprehensive learning experience and ensuring the effective application of ultrasound skills in clinical practise [20,31].

Which course formats and components fit the best for educating midwives in obstetric ultrasound?
The majority of research focuses on single-instance obstetric ultrasound training programs, spanning from a few days to several weeks, incorporating both theoretical knowledge and practical skills development [16,24].Various studies, including those by Bentley [14,16,23].
However, certain analyses reveal limitations regarding the adequacy of training duration for skill competency.Viner et al. suggested that a 5 day course fell short of fostering sufficient competency, recommending a minimum of 10 days to allow for ample hands-on experience [25].This perspective is echoed by Shaw-Battista et al., who advocated for increased scanning practise through additional sessions or extended training lengths to bolster educational outcomes and skill retention amongst midwives [28].Moreover, the implementation of refresher courses is identified as a beneficial strategy for reinforcing knowledge [20].
Johnston et al. underscored the critical role of integrating both theoretical and practical elements in the curriculum for teaching point-of-care ultrasound (POCUS) to midwives Fig. 3 Geographical distribution of included publications [15].Hands-on training is emphasized to be a very valued component of ultrasound courses [28].Programs rich in practical training are noted for their efficacy in translating complex content into clinically relevant skills [20].Furthermore, the frequency of practise, as evidenced by the number of scans performed during training, correlates positively with improved knowledge acquisition and selfefficacy [24].
The integration of simulation-based learning alongside clinical training is gaining prominence, particularly in obstetrics and fetal medicine.This blend of simulation and clinical practicum is shown to markedly enhance learner outcomes and competency in performing obstetric ultrasound independently on patients [21].
Inclusion of online modules within the training framework has received favorable evaluations, with participants particularly valuing the availability of preparatory materials, especially beneficial for those facing geographical constraints [20,28].
Additional components contributing to skill enhancement include structured in-course supervision to provide essential support and feedback, and the involvement of experienced sonographers during practical sessions, offering invaluable expertise to midwife trainees [15,24,28].

How are potential increases in knowledge and newly acquired skills measurable and assessable at the end of the course?
To evaluate the effectiveness of obstetric ultrasound training programs, a variety of assessment methodologies are employed, including multiple choice tests, questionnaires, and objective structured clinical examinations (OSCEs).It is common for research to integrate multiple forms of evaluation, facilitating a comparative analysis of participant's knowledge and skills before and after the course [14,16] (see Fig. 3).
Initial knowledge levels are often gauged via precourse assessments, typically comprising multiplechoice questions that cover essential domains such as the theoretical underpinnings of ultrasound technology, obstetric anatomical understanding, and patient communication strategies.Pre-course surveys may also be conducted to ascertain participants' baseline comfort with and experience in ultrasound, alongside their expectations regarding the training's impact.Post-course evaluations, mirroring the precourse assessments or incorporating specific content-related queries, enable a detailed appraisal of theoretical learning outcomes [16,17,20].
Practical proficiency is predominantly assessed through OSCEs, conducted after the course's completion [20].These examinations allow for the systematic evaluation of acquired skills, including the operation of ultrasound machinery, fetal positioning, and the execution of measurements for gestational age determination [14,32].A pass in the practical examination necessitates the successful completion of a set number of tasks, with participants' performances and the accuracy of their measurements benchmarked against those of seasoned professionals [14,25].
Additional methods to assess the training's impact include the review and discussion of images captured during practical sessions, formal assessments within the course framework by instructors, and the gathering of qualitative data through in-depth interviews and focus group discussions.These approaches provide nuanced insights into the participant's experiences, attitudes, and any encountered challenges [14,25,27,29].
For a comprehensive assessment of the sustainability of the skills and knowledge acquired, competency evaluations are recommended at intervals post-training, typically ranging from three to 6 months, and in some instances, extending up to a year.This longitudinal approach aids in determining the retention and application of the ultrasound competencies over time [14,16,24].

What are potential challenges and problems in existing courses, and how can they be overcome? Are there any particular needs and expectations for the future development of obstetric ultrasound education?
The literature on the implementation of obstetric ultrasound training for midwives highlights several challenges and obstacles in the delivery process and participant training [17,20].A predominant focus is on short-term courses, which, despite their prevalence, are often criticized for insufficient duration that inadequately addresses the teaching of practical skills [16,20,22,24].This has led scholars like Bentley et al. and Zimmermann et al. to advocate for the exploration of more frequent and iterative educational interventions [16,32].Both the duration of courses and more opportunities for practical experience are considerations to be acknowledged [28].
A notable impediment is the inability of midwives to disengage from their professional duties during training, which, coupled with trainers' concurrent clinical responsibilities, results in limited availability for essential supervised scanning sessions [20,25].Proposals have been made to negotiate dedicated time within work schedules to accommodate training needs [17].
Diversity in trainees' pre-existing knowledge and experience presents another challenge, indicating a need for early and more frequent practical assessments to identify varying levels of aptitude and to provide tailored support [17,28].Solutions include segregating trainees into subgroups based on their proficiency levels and offering courses in native languages or with interpreter support to bridge language barriers [17,20].
Longitudinal follow-up post-training is frequently lacking, limiting insights into the long-term impacts on patient care and clinical management [16,24].Future research is encouraged to address the effects of midwifeconducted ultrasound exams on patient outcomes [16].In addition, uncertainties related to accreditation, eligibility, and guidelines for ultrasound use by non-radiologists highlight a broader issue of policy deficiencies that need addressing to enhance ultrasound accessibility and utilization [23].
In LMICs, where most obstetric ultrasound training research for midwives is conducted, progress is significantly hindered by factors like inadequate infrastructure, geographic isolation, and resource limitations.The absence of sustained supervision and mentorship post-training exacerbates these challenges, affecting the development and confidence in POCUS skills [17,20].Teleultrasound and formal accreditation in POCUS with longitudinal mentorship have been proposed as solutions to these challenges [20].
Moreover, high costs, equipment failures, and the poor quality of mobile ultrasound units, combined with limited local technical support, call for more affordable device options, thorough pre-distribution equipment inspections, and contingency plans for equipment malfunction [17,20].Infrastructure issues, such as unstable power supplies and limited internet access, further complicate the implementation of tele-ultrasound, underscoring the necessity of stable infrastructure to support the growing importance of ultrasound in LMICs [27,33].

Which applications or tools are available to simplify the education of obstetric ultrasound to midwives?
To enhance the proficiency of midwives in the application of obstetric ultrasound and facilitate the acquisition of relevant skills, several studies have explored the utility of simulators and specialized ultrasound systems.Ultrasound simulators have been recognized as effective educational tools, offering an alternative to clinical training environments, which are often constrained by time limitations and the practical challenges of working with patients [34][35][36][37].Simulatorbased learning (SBL) provides a controlled, stress-free environment that enables learners to practise extensively and engage in inquiry without the apprehensions associated with patient interactions.This approach also circumvents issues related to patient recruitment, discomfort during prolonged examinations, and the psychological impact of being observed by patients [21,36].
Comparative studies assessing the efficacy of SBL have divided trainees into groups, with one having access to simulators and the other not.Findings indicate that simulators are beneficial for teaching fundamental ultrasound skills, offering a controlled learning environment that facilitates content delivery and enhances the rapidity and accuracy of ultrasound image acquisition [21,34,36,37].However, despite these advantages, final assessment outcomes do not demonstrate significant superiority over traditional methods, especially regarding long-term skill retention.Thus, integrating SBL with clinical practise is recommended to maximize competency development [21,34].
Despite its benefits, SBL is not without drawbacks, including high operational costs and the inability to replicate certain real-life conditions such as amniotic fluid dynamics, fetal movements, and the manipulation of fetal position [21,36].Differences in the appearance of anatomical structures on simulators compared to actual ultrasound machines have also been noted, underscoring the necessity of complementing SBL with hands-on clinical experience to achieve comprehensive ultrasound proficiency [37].
Technological advancements have also been explored to support midwives' training in obstetric ultrasound.Studies on the use of three-dimensional (3D) ultrasound technologies have aimed to facilitate the visualization of target anatomical structures, although the benefits appear to be limited to slight improvements in femoral length visualization at the expense of increased procedure time [38,39].
Telemedicine has emerged as a promising tool to bridge geographical gaps, particularly between novice midwives and experts in maternal-fetal health.Implementations such as web-based telemedicine systems, incorporating diagnostic devices and digital communication tools, have shown potential in enhancing the transmission of clinical data and images, as well as providing real-time guidance on ultrasound image acquisition and interpretation [35].
Integrated learning tools and tele-radiology systems have been developed to support midwives further, offering theoretical resources, decision-making aids, and the capability to transmit images for expert review [18,27,39].Despite high levels of satisfaction with these technological supports, challenges related to electrical and internet reliability may impede widespread adoption [27].

Discussion
This manuscript describes the significance and operationalization of obstetric ultrasound education for midwives, underlining its potential to substantially elevate the quality of maternal care.Existing literature and the current paradigm of ultrasound education in midwifery education were discussed.Several key elements being essential for an effective integration and sustainability of ultrasound training programs in midwifery education are presented.
The incorporation of obstetric ultrasound into midwifery practise empowers midwives to deliver a more holistic care model to pregnant women [15].This is particularly salient in remote and LMICs, where enhancing prenatal care resources through point-of-care ultrasound (POCUS) and telemedicine can significantly mitigate prevalent healthcare challenges, including high maternal and fetal mortality rates [17,20,30].POCUS, characterized by its portability and independence from traditional clinical settings, can alleviate economic burdens associated with accessing ultrasound facilities [17].
Educational programs in obstetric ultrasound typically encompass theoretical and practical dimensions, with an emphasis on hands-on training.This practical component, often facilitated through engagement with pregnant volunteers, is critical for transitioning to clinical phases where midwives apply their skills under supervision [17].In addition, the role of simulator-based learning (SBL) as a controlled and efficacious educational strategy is increasingly acknowledged within formal training contexts [37].
Despite these advancements, the initiation of ultrasound training within midwifery curricula encounters several challenges.A recurrent critique pertains to the insufficient duration of courses, which compromises the depth of practical skill development.The varied expertise amongst participants further complicates course delivery [22,28].Moreover, the absence of longitudinal follow-up posttraining limits insights into the enduring impacts on patient care and maternal and child health outcomes [16].The lack of standardized curricula, clear guidelines, and political backing further constrains the efficacy of ultrasound education [23,24].Specifically, in LMICs, infrastructural, technical, and personnel deficiencies impede the realization of educational goals [20,27].
Hence published recommendations emerge for optimizing obstetric ultrasound courses for midwives, by extending course durations to adequately cover essential content, reducing group sizes to enhance hands-on learning opportunities, and incorporating more frequent educational sessions [16,22,28].Longitudinal participant observation should be conducted to elucidate the impact of midwifeconducted ultrasound exams on healthcare outcomes [16,24].Adapting lectures to different levels of pre-existing knowledge and employing early and regular OSCEs can further improve the efficiency and effectiveness of learning [17,20,28].The integration of SBL with clinical practise is advocated to achieve comprehensive ultrasound competency and also alternative instructional modalities, such as online teaching, offer flexible learning opportunities, especially in remote areas [20,30,33,37].Furthermore, enhancing logistical support for accessing ultrasound training facilities, as well as ensuring dedicated time for midwives to engage in educational activities without workplace constraints can extend educational accessibility [20,30].
Design of ultrasound training programs for midwives seems to be a key factor for improving the quality of midwifery care.However, its proof concept and feasibility in clinical practise must first be evaluated.
While some midwives see benefits in the use of ultrasound, others suggest significant burdens.Considering the use of ultrasound to be a potential factor for medicalization, pregnancies might be at "risk" for additional or even unnecessary interventions [43,44].Such concerns need to be acknowledged.
Our systematic literature review shows that most findings emerge from initiatives in LMICs outside Europe (Fig. 3).Focusing on local challenges to enhance prenatal care quality, conditions of midwives are markedly different from industrialized nations like Germany.As the range of tasks characterizes the scope of training, implementation of programs are in accordance with local regulations.Benefits and improvements of perinatal care cannot easily be transferred from developing country to industrialized, or vice versa.
Focusing on industrialized countries, large distances between rural regions and specialized birth centers, with high-risk pregnancies might by supported.Thus enhance the access to essential prenatal diagnostics for underserved areas and contributing to the improvement of prenatal care.Moreover, considering the frequently high workload in clinical settings, promoting interdisciplinary collaboration between midwives and obstetricians/gynecologists could be facilitated by midwives assuming sonographic responsibilities [45].This capability becomes particularly valuable in obstetric emergency scenarios, where midwives could provide prompt and efficient initial evaluations.Such a shift not only improves the quality of the midwife's prescribed activities but also integrates seamlessly with the ongoing academization of the profession in Germany.Reflecting this trend, since 2020, numerous German cities have seen the establishment of bachelor's degree programs in midwifery as part of the academization process [46].Consequently, incorporating ultrasound training for midwives in Germany would happen within or alongside these bachelor's degree programs.However, a close look at the curriculum of the degree program reveals that the predetermined schedule limits in-depth experience with prenatal care, particularly for high-risk pregnancies.Thus, it's essential to consider alternative approaches to optimize the instruction of ultrasound training within Germany's midwifery education system.Incorporating ultrasound training into a Master's degree course could be an effective strategy to prevent adding to the academic burden within current study structures and to ensure ultrasound training is not merely a voluntary option.This approach could offer further training as an Advanced Practical Midwife, allowing for a deeper and more focused engagement, more time to gain experience and enhancing quality assurance.Simultaneously, a standardized curriculum is necessary to streamline the educational process and to ensure uniform knowledge of ultrasound techniques and their application in maternal and fetal health.Collaborative effort is essential amongst educational institutions, professional associations, healthcare policymakers, regulatory bodies, and practitioners including midwives, obstetricians, and ultrasound experts.In this context of creating a cohesive educational framework, it is vital to proactively assess anticipated expenses, including equipment costs and their integration into daily practise, as well as to explore options for financial coverage.Without specific cost data, discussions remain speculative and could lead to resistance, especially amongst freelance midwives.Current maternity care guidelines do not cover funding for ultrasound examinations by midwives, creating a policy gap that may limit the use of this diagnostic tool.
In case of responsibility toward pregnant woman, particularly with regard to alternative approaches such as care via telemedicine, it is imperative to establish clear, binding guidelines that define the scope, roles, and responsibilities of each profession involved, ensuring a harmonious and efficient collaboration.Especially role allocation in ultrasound between midwives and obstetricians/ gynecologists (OB-GYNs) remains a central topic, which will subsequently influence the midwifery curriculum.In this context, it is important to emphasize that ultrasound training for midwives cannot be compared to the extensive and detailed training that OB-GYNs receive, particularly regarding quality.The purpose of introducing ultrasound to midwives is not to supplant or replace the medical profession but, as already mentioned, to improve the quality of midwifery work.However, this particular matter-the uncertain future trajectory of ultrasound training for obstetrics/gynecology, as recently explored in the publication by Recker et al. [45]-remains a topic of intense debate and significant interest.Nevertheless, the evolution of midwifery education and profession is present and it is foreseeable that midwives will increasingly provide antenatal care.Therefore, it is crucial to examine the benefits of ultrasound training in adapting to these changes and future direction of midwifery to equip midwives for the evolving demands of prenatal care [45].
Further research and dialogue are needed to assess the opportunities, as well as the efficacy and sustainability of ultrasound training within midwifery education in Germany, focusing on standardized curriculum development and addressing financial and regulatory challenges.It is crucial to determine the long-term impacts of ultrasound training on the midwifery profession and its evolving role in prenatal care.In addition, a clear delineation of roles and responsibilities between midwives and other healthcare professionals is necessary to ensure that ultrasound is used effectively and appropriately in maternal care, optimizing outcomes for pregnant women.
This systematic review acknowledges its limitations, given the dynamic nature of research in obstetric ultrasound education for midwives, and recognizes the potential for new studies to have emerged during its compilation.

Conclusion
The provision of obstetric ultrasound training to midwives represents a pivotal advancement in prenatal care, significantly bolstering their ability to deliver comprehensive care to both mothers and newborns.In the quest for optimizing educational outcomes, a diverse array of pedagogical strategies and learning modalities has been explored.Enhancements in the structure of such training, specifically through the extension of course durations and increased frequency of sessions, alongside sufficient allotment for hands-on practise, are posited to substantially improve midwives' ultrasound proficiency.Moreover, the implementation of tailored group formations, based on competency levels, can further refine learning efficiency.
Critical to the transition of trainees into clinical settings is the provision of robust mentorship and supervisory frameworks, ensuring the practical application of acquired skills under guided oversight.Future research endeavors should pivot towards evaluating the long-term ramifications of ultrasound training on clinical outcomes, thereby substantiating its impact on maternal and neonatal health.
Nevertheless, the landscape of ultrasound education for midwives is marred by systemic challenges, necessitating policy reforms and the adoption of standardized training curricula to navigate through these complexities effectively.These challenges extend beyond educational frameworks, encompassing financial difficulties and the broader implications of integrating ultrasound training into the midwifery profession and its pivotal role in prenatal care.Addressing these existing barriers is imperative for creating an educational ecosystem that is effective, consistent, and sustainable.As we continuously refine and expand ultrasound training paradigms for midwives, it becomes evident that such efforts mark a significant stride towards improving the quality of maternal and neonatal healthcare services.
Funding Open Access funding enabled and organized by Projekt DEAL.The authors have not disclosed any funding.

Fig. 1
Fig. 1 Study selection process according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines

Fig. 2
Fig. 2 Summary of different learning approaches and assessment formats in obstetric ultrasound training for midwives et al. with a 1 week course, Viner et al. with a 10 day course, and Kim et al. with a 2 day course, demonstrate the effectiveness of these formats in enhancing midwives' knowledge, confidence, and clinical proficiency in ultrasound application.Results from these investigations indicate significant gains across both extensive and concise training durations

Table 2
Included studies and their characteristics

Table 3
Included studies focused on simulation and further technological aids

Table 4
Included reports