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However, correlations varied considerably in between countries (Table 2 & Fig. The mean difference between US and any of the other methods was less than 1 week overall (LMP: 0.34 weeks, SFH: 0.40 weeks, BS: 0.80 weeks) but showed great intercountry variations (Table 2 & Fig. The 95% limits of agreement were considerable (LMP:-7.9 to 8.6 weeks, SFH: − 4.9 to 5.8 weeks, BS: − 3.5 to 5.1 weeks) and again showed great variation in the different countries (Table 2 & Fig. The sensitivity analyses including women ≥24 weeks’ gestation at enrolment into the study showed results consistent with the main analyses for BS with mean difference of 0.66 weeks (Pearson r = 0.27, 95% limit of agreement − 4.1to 5.4, range of averages 27.29–43.21) and higher mean differences for LMP with 1.15 weeks (Pearson r = 0.33; 95% limit of agreement − 7.9 to 10.1, range of averages 25.21–50.14 weeks) and SFH with 0.89 weeks (Pearson r = 0.63, 95% limit of agreement − 4.9 to 6.3, range of averages 22.14–46.85 weeks).
Using ultrasound as the reference, 1391 mothers delivered term babies compared to 239 preterm babies ( 24 weeks gestational age at enrolment the sensitivity analyses showed no major difference in trends with regards to agreement between methods for BS but showed higher mean difference in weeks for SFH suggesting an increasing variation .
Determining gestational age in resource-poor settings is challenging because of limited availability of ultrasound technology and late first presentation to antenatal clinic.
Last menstrual period (LMP), symphysio-pubis fundal height (SFH) and Ballard Score (BS) at delivery are therefore often used.
Comprehensive quality assurance and quality control (QA/QC) systems were put in place to ensure the quality and reliability of measurements, and the inter-site comparability of US measurements.
This included centrally purchased equipment, a standard operating procedure (SOP) which was applicable and mandatory across all sites (Additional file 1), two specifically dedicated staff per site to carry out all US measurements and central training before study start.
We assessed the accuracy of LMP, SFH, and BS to estimate gestational age at delivery and preterm birth compared to ultrasound (US) using a large dataset derived from a randomized controlled trial in pregnant malaria patients in four African countries.
The mean gestational age at delivery using US was 38.7 weeks (95%CI: 38.6–38.8, median: 38.9 weeks, range: 23.1–44.8 weeks), by LMP was 38.4 weeks (95%CI: 38.0–38.9, median: 38.7 weeks, range: 22.9–60.9 weeks), by SFH was 38.3 weeks (95%CI: 38.2–38.5, median: 38.3 weeks, range: 21.1–49.7 weeks) and by BS was 38.0 weeks (95%CI: 37.9–38.1, median: 38.0 weeks, range: 28.0–42.0) (p Correlation between US and any of the other three methods was poor to moderate (LMP: r = 0.38, SFH: r = 0.63, BS: r = 0.31).
Gestational age was calculated based on biparietal diameter, abdominal circumference, and femur length  using standard algorithms .