title: Gestational Age Assessment in the Ghana Randomized Air Pollution and Health Study (GRAPHS): Ultrasound Capacity Building, Fetal Biometry Protocol Development, and Ongoing Quality Control.
abstract: BACKGROUND
  Four million premature deaths occur yearly as a result of smoke from cooking fires. The Ghana Randomized Air Pollution and Health Study (GRAPHS) is underway in the Kintampo North municipality and South district of rural Ghana to evaluate the impact of improved cook stoves introduced during pregnancy on birth weight and childhood pneumonia. These hypotheses are being tested in a cluster-randomized intervention trial among 1415 maternal-infant pairs within 35 communities assigned to a control arm (traditional cooking) or one of two intervention arms (cooking with an improved biomass stove; cooking with liquefied petroleum gas stoves).
  
  
  OBJECTIVE
  The trial is designed to ensure delivery of the stove intervention prior to the period of maximal fetal growth. To answer questions about the impact of household air pollution on pregnancy outcome, accurate gestational age assessment is critical. This manuscript describes in detail the development of the gestational dating protocol, intensive ultrasound training involved, ultrasound capacity building, and ultrasound quality control program.
  
  
  METHODS
  Ultrasound training occurred in several phases over the course of 2 years. Training included a basic obstetric ultrasound course offered to all midwives performing antenatal care at the two study hospitals, followed by a more intense period of hands-on training focused on fetal biometry for a select group of providers demonstrating aptitude in the basic course. A standard operating procedure was developed describing how to obtain all fetal biometric measurements. Consensus was obtained on how biometric images are used in the trial to establish gestational age and estimate the delivery date. An ongoing ultrasound quality control program including the use of an image scorecard was also designed.
  
  
  RESULTS
  Publication of trial results is anticipated in late 2016.
  
  
  CONCLUSIONS
  Use of ultrasound should be strongly considered in field-based trials involving pregnant women to accurately establish gestational age, as menstrual dates may be incorrect or unknown. The inclusion of ultrasound in areas where ultrasound capacity does not previously exist requires a significant investment of time and resources. Such investment ensures appropriate training, high quality images, and accurate dating pregnancies. We outline our ultrasound training, image acquisition, quality control, and dating protocols in detail.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT01335490; http://clinicaltrials.gov/ct2/show/NCT01335490 (Archived by WebCite at http://www.webcitation.org/6UbERJNO6).
authors.affiliation: Kintampo Health Research Centre, Brong Ahafo Region, Kintampo, Ghana.
authors.forename: Ellen A
authors.identifier: http://orcid.org/0000-0001-6148-7332
authors.initials: EA
authors.lastname: Boamah
authors.forename: Kp
authors.identifier: http://orcid.org/0000-0001-9158-351X
authors.initials: K
authors.lastname: Asante
authors.forename: Ka
authors.identifier: http://orcid.org/0000-0001-5638-4814
authors.initials: K
authors.lastname: Ae-Ngibise
authors.forename: Patrick L
authors.identifier: http://orcid.org/0000-0003-2801-1003
authors.initials: PL
authors.lastname: Kinney
authors.forename: Darby W
authors.identifier: http://orcid.org/0000-0002-9932-0201
authors.initials: DW
authors.lastname: Jack
authors.forename: Grace
authors.identifier: http://orcid.org/0000-0002-6839-5091
authors.initials: G
authors.lastname: Manu
authors.forename: Irene T
authors.identifier: http://orcid.org/0000-0003-1101-1373
authors.initials: IT
authors.lastname: Azindow
authors.forename: Seth
authors.identifier: http://orcid.org/0000-0002-0807-1781
authors.initials: S
authors.lastname: Owusu-Agyei
authors.forename: Blair J
authors.identifier: http://orcid.org/0000-0003-4818-1050
authors.initials: BJ
authors.lastname: Wylie
keywords: biometry; capacity building; gestational age; household air pollution; ultrasound