Estimation of the gestational age in singleton pregnancy using symphysis fundal height measurement in Africa. A scoping review protocol.

INTRODUCTION Globally symphysis fundal height measurement (SFH) is a commonly used method to estimate gestational age globally. Among other methods that are used to estimate the gestational age are the last normal menstrual period (LMP) if it is performed early in pregnancy, early abdominal ultrasound, and New Ballard score which is done on the new born baby after delivery (Rada et al., 2018) SFH measurement is the most used tool to estimate the gestational age and to monitor fatal growth in low and middle income and developing countries where ultrasound services are not always available (Rada et al., 2018). Estimation of gestational age is done to exclude risks such as intrauterine growth retardation (IUGR), multiple pregnancy, polyhydramnios, and oligohydramnios. If the risks are not identified, this may lead to undiagnosed conditions which will then lead to mismanagement. Literature search was done on systematic, scoping, and meta-analysis reviews that were conducted on SFH. Scoping review is regarded as one of the newer review types adapted to clarify the operational definitions and conceptual boundaries of a topic (Peters et al., 2020). Whelan et al. (2022) conducted a systematic review of symphysis fundal height (SFH) measurement in low- and middle-income countries (LMIC). The aim was to look at the methods of SFH measurement and assess the accuracy of SFH in the estimation of gestational age. During this review different databases were searched from January 1980 to November 2021 and the grey literature was included. Inclusion and exclusion eligibility criteria were applied. About 37 out of 1,003 studies that were reporting the comparison between SFH measurement and other methods were included in the study. The findings revealed that SFH is underestimated in comparison with ultrasound, therefore it is not recommended for gestational age aging. Despite these findings SFH measurement is still used worldwide. Goto, (2020) conducted a meta-analysis to assess the diagnostic value of SFH to identify large for gestational age among the two developing African countries. There was no evidence that SFH can estimate low for gestation babies or large babies. (Mabrouk et al., 2022) conducted a scoping review of preterm births in sub-Saharan Africa. Although SFH was among the methods that were used to estimate gestational age, last menstrual period was found to be the most useful method. The literature on SFH measurement shows that it is still used globally and locally especially if the woman is not sure of her menstrual dates and in the absence of ultrasound services. This scoping review will identify the gaps and will map the evidence and rate at which SFH is used to estimate the gestational age. It will also be used to assist in the triaging of patients at risk and their diagnosis thereof. Munn et al. (2018) described the scoping review as “an ideal tool to determine the scope or coverage of a body of literature on a given topic and give a clear indication of the volume of literature and studies available as well as an overview (broad or detailed) of its focus”. Scoping review was introduced to synthesize the evidence of primary research conducted in the health care field. The scoping review may be conducted to summarize and disseminate the findings. It may be undertaken to identify the research gaps and give recommendations necessary for future research Peters et al., (2020). The reviewer has searched PubMed and Google scholar databases for the studies (systematic, scoping, and meta-analysis reviews) conducted on the estimation of gestational age and fetal growth monitoring. The following purposes of conducting the scoping review were reported by (Munn et al., 2018) in their study to describe the guidance for authors when choosing between the systematic and scoping review: a) To identify the types of available evidence in each field b) To clarify key concepts/ definitions in the literature c) To examine how research is conducted on a certain topic or field d) To identify key characteristics or factors related to a concept e) As a precursor to a systematic review INTRODUCTION Globally symphysis fundal height measurement (SFH) is a commonly used method to estimate gestational age globally. Among other methods that are used to estimate the gestational age are the last normal menstrual period (LMP) if it is performed early in pregnancy, early abdominal ultrasound, and New Ballard score which is done on the new born baby after delivery (Rada et al., 2018) SFH measurement is the most used tool to estimate the gestational age and to monitor fatal growth in low and middle income and developing countries where ultrasound services are not always available (Rada et al., 2018). Estimation of gestational age is done to exclude risks such as intrauterine growth retardation (IUGR), multiple pregnancy, polyhydramnios, and oligohydramnios. If the risks are not identified, this may lead to undiagnosed conditions which will then lead to mismanagement. Literature search was done on systematic, scoping, and meta-analysis reviews that were conducted on SFH. Scoping review is regarded as one of the newer review types adapted to clarify the operational definitions and conceptual boundaries of a topic (Peters et al., 2020). Whelan et al. (2022) conducted a systematic review of symphysis fundal height (SFH) measurement in low- and middle-income countries (LMIC). The aim was to look at the methods of SFH measurement and assess the accuracy of SFH in the estimation of gestational age. During this review different databases were searched from January 1980 to November 2021 and the grey literature was included. Inclusion and exclusion eligibility criteria were applied. About 37 out of 1,003 studies that were reporting the comparison between SFH measurement and other methods were included in the study. The findings revealed that SFH is underestimated in comparison with ultrasound, therefore it is not recommended for gestational age aging. Despite these findings SFH measurement is still used worldwide. Goto, (2020) conducted a meta-analysis to assess the diagnostic value of SFH to identify large for gestational age among the two developing African countries. There was no evidence that SFH can estimate low for gestation babies or large babies. (Mabrouk et al., 2022) conducted a scoping review of preterm births in sub-Saharan Africa. Although SFH was among the methods that were used to estimate gestational age, last menstrual period was found to be the most useful method. The literature on SFH measurement shows that it is still used globally and locally especially if the woman is not sure of her menstrual dates and in the absence of ultrasound services. This scoping review will identify the gaps and will map the evidence and rate at which SFH is used to estimate the gestational age. It will also be used to assist in the triaging of patients at risk and their diagnosis thereof. Munn et al. (2018) described the scoping review as “an ideal tool to determine the scope or coverage of a body of literature on a given topic and give a clear indication of the volume of literature and studies available as well as an overview (broad or detailed) of its focus”. Scoping review was introduced to synthesize the evidence of primary research conducted in the health care field. The scoping review may be conducted to summarize and disseminate the findings. It may be undertaken to identify the research gaps and give recommendations necessary for future research Peters et al., (2020). The reviewer has searched PubMed and Google scholar databases for the studies (systematic, scoping, and meta-analysis reviews) conducted on the estimation of gestational age and fetal growth monitoring. The following purposes of conducting the scoping review were reported by (Munn et al., 2018) in their study to describe the guidance for authors when choosing between the systematic and scoping review: a) To identify the types of available evidence in each field b) To clarify key concepts/ definitions in the literature c) To examine how research is conducted on a certain topic or field d) To identify key characteristics or factors related to a concept e) As a precursor to a systematic review a) What is the evidence of studies conducted to estimate the gestational age in single pregnancy using SFH measurement in Africa? b) What are the different methods used to estimate gestational age in single pregnancy in Africa? Scoping review questions Methodology A scoping review protocol will be developed according to the Joanna Briggs Institute (JBI) Manual (Peters et al., 2022). Protocols provide the reviewers with the direction on how to conduct and report the scoping review results. Protocols also specify the inclusion and exclusion criteria, databases and the search strategy that will be adopted (Peters et al., 2022). The reviewer will register the scoping review in JBI to avoid unintended duplication of reviews. When conducting a scoping review, the researcher will follow the steps as described in the (JBI) manual. These steps differ from those that are used when conducting the traditional systematic reviews because the scoping review addresses the broader gaol as opposed to the systematic review (Peters et al., 2022). The number of articles searched will be presented in Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews PRISMA-ScR) checklist. The aim of the PRISMA-ScR is to help readers to understand the relevant items to be reported for scoping reviews (Tricco et al., 2018). Eligibility criteria Scoping review Objective When developing search terms, inclusion, and exclusion criteria, the researcher will apply the Population, Concepts, Context (PCC) framework as indicated in the table below. Table 1 PCC: Search terms and eligibility criteria Variable Description Inclusion criteria Exclusion criteria Population Pregnant women, pregnant mothers or expecting mothers, antenatal patients (A pregnant woman is a woman attending antenatal care clinic with a singleton pregnancy) -Articles written in English language -Studies conducted on singleton pregnancy between 18 and 36 weeks of gestation - SFH and gestational age articles published between 2013 and 2023 -Articles not written in English -Studies not conducted on singleton pregnancy and not between 18 and 36 weeks of gestation -SFH and gestational age studies conducted before 2013 Concept Estimation of gestational age, gestational aging, fetal growth monitoring, symphysis fundal height measurement -Studies conducted in low- and middle-income countries, low socio economic or remote countries to obtain the latest information on gestational ageing and the most used methods. -All studies conducted to estimate gestational age using SFH measurement and other methods (Ultrasound, menstrual data) to estimate gestational age or to monitor fetal growth -All studies with SFH measured in successive antenatal visit. Context Africa*, OR African countries* OR developing countries*, OR low resource countries*, OR low- and middle-income countries* -All studies conducted in Africa, developing countries, low resource countries, low- and- middle income countries -All studies conducted in developed countries, high-income countries Search strategy The search strategy will include the keywords symphysis fundal height, gestational age, fetal growth monitoring, estimation of gestational age, gestational aging, Africa, low socio-economic countries, low- middle income countries, developing countries. When searching using the keyworks, the researcher will apply PCC (Population, Concept, Context) framework. The search strategy will also use the index terms when searching the identified databases (Peters et.al, 2020) The literature search will include the studies written in English and conducted between 2013 and 2023. There will be no design limiters during literature search, any study design will be included. During the initial search, the reviewer will screen the titles and abstracts of papers that have been searched using two databases PubMed and EbscoHost. To refine the search terms, key words and MeSH terms will be discussed with the review team (Peters et.al, 2020) In step two the following databases will be searched: UKZN library, Ebscohost, PubMed, CINAHL, Google scholar and Web of Science will be used to search for the relevant articles of primary studies of systematic reviews, and meta-analyses. Grey literature will also be searched in the form of dissertations and theses, and World health organization reports (WHO). In step three the searching of the reference list of the articles included will be done. The key authors of the reviews and primary studies will be contacted should the additional information be required (Peters et al., 2022). The review team, with the help of the subject librarian will apply the eligibility criteria to screen the articles. During literature search, the reviewers will use the Boolean operators OR and AND. To broaden the search, operator OR and truncations will be used. Operator OR will also be used to connect the synonyms for example fetal growth monitoring OR estimation of gestational age. Operator AND will be used to connect the key words for example symphysis fundal height and Africa (Mabrouk et al., 2022). Relevant studies obtained from the search will be imported to the endnote version 20.5. Rayyan software will also be used for the documentation and management of the results (Peters et al., 2022) Query Results Time Search: ((Symphysis fundal height measurement) OR (Fetal growth monitoring)) AND (africa) Filters: Abstract, Free full text, Full text, in the last 10 years 78 05:30:09 Search: (( Africa) AND (Symphysis fundal height measurement)) OR (Fetal growth monitoring) Filters: Abstract, Free full text, Full text, in the last 10 years 1,847 05:28:03 Search: Symphysis fundal height measurement OR fetal growth monitoring AND African countries Filters: Abstract, Free full text, Full text, in the last 10 years 10 05:21:00 Figure 1. Sample of search strategy conducted in April 2023 Process of source selection During the first phase of source selection the review team will remove the duplicates and then will independently screen the titles and abstracts of papers that have been searched. About 15 articles will be piloted and screened by three reviewers who will be functioning independently with Blind On. The agreement level for the piloted articles will be greater than 75 %. Studies which do not meet the inclusion criteria will be excluded (Arksey & O'Malley, 2005). Secondly the inclusion and exclusion criteria will be applied to screen the full text of the papers. PCC framework recommended by the JBI will be adopted when selecting the studies. If new terms, concepts, and sites of evidence are revealed during the review process, searches will be modified (Peters et al., 2022) Data extraction A draft charting table will be developed and used to extract data using the PCC variables. To answer the review questions, the information in table 2 will be included as listed in JBI manual (Peters et al., 2022) Table 2: Draft charting table for the symphysis fundal height measurement in Africa Developing African countries Author/year of study Topic /Country Population Concept Context Methods Relevant results and findings - The reviewers will pilot the charting template on two or three articles to ensure that the required data is added - The reviewers would ascertain if the data extracted is consistent with the review questions and the inclusion criteria, they will also familiarize themselves with the form. - During data extraction process, the reviewers will revise and modify charting of data - Three reviewers will double check the data independently, and the fourth reviewer will be involved to ensure that the consensus is reached. They will focus on the following data: Author(s), year of publication, country of origin (where the study was published or conducted), aims/purpose of the study, study population if applicable, method ology/methods, intervention, type or duration and key findings that relate to the scoping review question/s (Peters et al., 2022) - If there is additional or missing information required, the reviewers will contact the key authors. Collating, summarizing, and reporting results Figures and tables will be used to chart and present the extracted data. The results will be analysed using a descriptive and narrative analysis. During the narrative analysis, the emerging themes will be identified and interpreted. The reviewers will summarize the findings and report how they will be published. The methodologies used, population and the identified gaps will also be reported, including the methods used to estimate gestational age. Dissemination of data will be done through presentation of results at local conference, and they will be submitted to a relevant journal for publication. Quality appraisal The quality of the articles included will be evaluated by using the Mixed Method Appraisal Tool (MMAT) version 18. Five categories of research will be appraised which are: qualitative and quantitative research, randomised controlled trials, non -randomised control trials, and mixed methods studies (Hong et al., 2018). Three independent reviewers will do the quality appraisal. The reviewers will use percentage scores to grade the quality of evidence. The scores will be interpreted as follows: A) ≤50 % - will be graded as low-quality evidence B) 51-75 % - will be graded as average evidence C) 76-100 %- will represent high quality evidence (Maluleke et al., 2021) Discussion This scoping review will evaluate the evidence in the use of SFH measurement in the estimation of gestational age and monitoring of fetal growth. The reviewers will be looking at the different methods that are used in Africa to estimate the gestational age. To evaluate the quality of articles included in the review, the reviewers will use the MMAT. This review will identify gaps in the plotting of SFH and make relevant recommendations. The report will emphasize the importance of SFH measurement since the SFH graph can assist in the triaging of women at risk. The findings from this scoping review will be useful in the development of curriculum for the student midwives (both theory and clinical) and will also inform the stakeholders when developing the policies. References Arksey, H., & O'Malley, L. (2005). Scoping Studies: Towards a Methodological Framework. International Journal of Social Research Methodology: Theory & Practice, 8, 19-32. doi.org Hong, Q. N., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M.-P., Griffiths, F., Nicolau, B., O’Cathain, A., Rousseau, M.-C., Vedel, I., & Pluye, P. 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