Radiopaedia.org

Variation in fetal presentation

  • Report problem with article
  • View revision history

Citation, DOI, disclosures and article data

At the time the article was created The Radswiki had no recorded disclosures.

At the time the article was last revised Yuranga Weerakkody had no financial relationships to ineligible companies to disclose.

  • Delivery presentations
  • Variation in delivary presentation
  • Abnormal fetal presentations

There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os . This includes:

cephalic presentation : fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations which include

left occipito-anterior (LOA)

left occipito-posterior (LOP)

left occipito-transverse (LOT)

right occipito-anterior (ROA)

right occipito-posterior (ROP)

right occipito-transverse (ROT)

straight occipito-anterior

straight occipito-posterior

breech presentation : fetal rump presenting towards the internal cervical os, this has three main types

frank breech presentation  (50-70% of all breech presentation): hips flexed, knees extended (pike position)

complete breech presentation  (5-10%): hips flexed, knees flexed (cannonball position)

footling presentation  or incomplete (10-30%): one or both hips extended, foot presenting

other, e.g one leg flexed and one leg extended

shoulder presentation

cord presentation : umbilical cord presenting towards the internal cervical os

  • 1. Fox AJ, Chapman MG. Longitudinal ultrasound assessment of fetal presentation: a review of 1010 consecutive cases. Aust N Z J Obstet Gynaecol. 2006;46 (4): 341-4. doi:10.1111/j.1479-828X.2006.00603.x - Pubmed citation
  • 2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon

Incoming Links

  • Obstetric curriculum
  • Cord presentation
  • Polyhydramnios
  • Footling presentation
  • Normal obstetrics ultrasound - third trimester singleton

Promoted articles (advertising)

ADVERTISEMENT: Supporters see fewer/no ads

By Section:

  • Artificial Intelligence
  • Classifications
  • Imaging Technology
  • Interventional Radiology
  • Radiography
  • Central Nervous System
  • Gastrointestinal
  • Gynaecology
  • Haematology
  • Head & Neck
  • Hepatobiliary
  • Interventional
  • Musculoskeletal
  • Paediatrics
  • Not Applicable

Radiopaedia.org

  • Feature Sponsor
  • Expert advisers

presentation in ultrasound report

  • How It Works
  • Report Reader
  • MyCare Navigator
  • Patient Blog
  • Privacy & Security
  • PocketHealth Overview
  • PocketHealth for Patients
  • Appointment Reminders
  • Follow-Up Navigator
  • PocketHealth for Providers
  • Community Gateways & Auto-Routing
  • Case Studies
  • PocketHealth vs Legacy Solutions
  • Contact Support
  • Patient FAQ
  • Have an access page?

How to Read a Pregnancy Ultrasound Report: Decoding Common Terminology

pregnancy ultrasound report

During pregnancy, you’ll likely have multiple ultrasounds to monitor the growth and health of your baby. Learn how to decipher the terms in your pregnancy ultrasound report.

Fetal ultrasounds are a standard prenatal screening tool and medical imaging test used to monitor your health and the health of your baby during pregnancy.

While pregnancy ultrasounds are a reliable way to track and measure your baby’s progress, reviewing your ultrasound report can be daunting. Pregnancy ultrasound reports often include acronyms and medical terminology that the average person may not recognize and knowing how to read ultrasound numbers and measurements can be intimidating.

If you’re experiencing anxiety waiting to review your ultrasound imaging test results with your OBGYN, family doctor or midwife, this article can help you decode the abbreviated medical language and terms in your report.

By understanding the terms in your ultrasound, you can stress less before your appointment and have confident, informed conversations with your healthcare team.

How does a pregnancy ultrasound work?

During your fetal ultrasound examination, a trained technician called a sonographer will use a hand-held device called a transducer to create and capture sound waves. Too high pitched for human ears to hear, those sound waves travel through your body and bounce off different structures in different ways. The ultrasound machine detects and uses these signals to create an image of the position and shape of your growing pregnancy. These captured images are then interpreted by a radiologist.

There are two main types of ultrasound procedures done during pregnancy:

  • Transabdominal scan (TAS): A sonographer will squeeze gel onto your belly and then run the transducer over the surface of your skin to capture the fetal anatomy of your growing baby.
  • Transvaginal scan (TVS): A sonographer will insert a lubricated wand into your vagina to capture more detailed images of your uterus, ovaries and fallopian tubes, allowing for a closer look at your pregnancy and determining any early pregnancy complications.

Early in your pregnancy, you’ll likely have both an abdominal ultrasound and transvaginal ultrasound, since the embryo is so small that the transducer successfully captures more details inside the vaginal canal than it can outside the abdomen. From the second trimester onwards, you’ll likely only have abdominal ultrasounds.

How to read a fetal ultrasound report

What does BPD mean on an ultrasound? What about CRL? Here’s an alphabetical list of the most common medical acronyms you’ll encounter when reviewing your pregnancy ultrasound results, with an explanation of each.

AC (Abdominal circumference):

The measurement of the fetus’s abdomen used to assess fetal growth and development.

AF (Amniotic fluid):

A clear liquid that surrounds the fetus during pregnancy. Contained in the amniotic sac, AF helps cushion the fetus, allowing for safe movement and regulating environmental temperature. AF can be measured using the Amniotic Fluid Index at any time after the 24-week mark of a pregnancy.

BPD (Biparietal diameter):

A standard used to assess fetal growth and development by measuring the distance between two sides of a fetus’ head. What does BPD mean for your ultrasound? BPD can help your practitioner determine gestational age when measured between 14 and 20 weeks of pregnancy.

CPR (Cerebroplacental ratio):

An obstetric tool used to measure fetal growth and adverse pregnancy outcomes by assessing cardiac output. CPR is typically measured within 2 weeks of delivery to determine placental sufficiency before delivery.

CRL (Crown-rump length):

A measurement of the embryo or fetus from the top of its head to the bottom of its torso used to estimate gestational age. CRL is used to assess age between weeks 6 and 13 of pregnancy, after which other measurements like BPD and head circumference (HC) may be more accurate.

EDD (Estimated date of delivery):

A calculation to determine the most likely date of spontaneous natural birth. EDD can be determined by reviewing ovulation and menstruation dates prior to conception or by examining the size of the uterus through a pelvic exam.

EFW (Estimated fetal weight):

EFW is a measurement determined by assessing the size and measurements of various parts of a fetus, including the head circumference (HC), abdominal circumference (AC) and femur length (FL). EFW can be determined at any point after the 10-week mark of a pregnancy.

FGR (Fetal growth restriction):

Is defined as a low fetal weight less than the 10th percentile in weight for gestational age, taking into consideration the growth potential of the fetus. Depending on the fundal height—the distance between the pubic bone and the top of the uterus—FGR may be assessed throughout the pregnancy.

FHM (Fetal heart rate monitoring):

Monitoring fetal heart rate movements allows your healthcare provider to assess the health of the fetus. The fetus’ FHM can be assessed internally using a transvaginal ultrasound in early pregnancy or externally using a Doppler ultrasound during later stages of pregnancy or labor.

FL (Femur length):

A measurement of the length of the fetus’ thighbone used to help estimate fetal growth and assess development. FL is measured during the second and third trimesters of pregnancy.

GA (Gestation age):

This measurement determines the age of the pregnancy and helps assess the health of the mother and fetus. GA can be determined by reviewing the LMP date, fundal height and ultrasound images.

GS (Gestational sac):

The gestational sac is a fluid-filled structure that surrounds and protects the embryo during the first weeks of pregnancy. Measuring the diameter of the GS during an ultrasound can help determine gestational and fetal age and assess the health of the pregnancy. This measurement is called the mean gestational sac diameter (MSD) and may be taken in the first trimester.

HC (Head circumference):

A measurement of the circumference of the fetus’ head used to determine fetal growth and development in combination with BPD, FL and AC measurements. HC is measured during the second and third trimesters of pregnancy.

LGA (Large gestational age):

LGA is a descriptor indicating that a newborn baby weighs more than usual for the length of pregnancy. LGA indicators can be assessed after the 20th week of pregnancy and may be determined by ultrasound or monitoring the mother’s weight gain during pregnancy.

LMP (Last menstrual period):

Date of the mother’s last menstrual period is used to determine the date of delivery and may be requested at the beginning of pregnancy to determine the length of gestation and approximate delivery date.

MSD (Mean gestational sac diameter):

The measurement of the GS using an ultrasound. This measurement determines the gestational age and expected due date of a pregnancy.

NT (Nuchal translucency):

The measurement of the amount of fluid behind the neck of a developing fetus. NT can be assessed by ultrasound between the 11th and 13th week of pregnancy and helps determine the risk of Down Syndrome and other genetic conditions in the developing fetus.

OFD (Occipital-frontal diameter):

Used to assess the growth and development of the fetus, the OFD is the measurement between the back of the head and the forehead of the fetus. This measurement is taken during the second and third trimesters of pregnancy and can be used in combination with BPD to determine the shape of the head.

SGA (Small for gestational age):

SGA is a descriptor indicating that a newborn baby weighs less than usual for the length of pregnancy. SGA indicators can be assessed after the 20th week of pregnancy and may be determined by ultrasound, checking placental blood flow or monitoring the mother’s weight gain during pregnancy.

How PocketHealth can help you access and understand your fetal ultrasound report

You’ll likely be eager to review your prenatal ultrasound images and results. PocketHealth gives you quick access to your pregnancy ultrasound images and reports, as soon as they’re released by the hospital imaging department or imaging clinic—often before your scheduled appointment with your OBGYN, referring family doctor or midwife. You can also securely store your results to any device and share the high-quality images with friends and family during all stages of your pregnancy. Access your records here.

The medical terms, acronyms and assessments found in your ultrasound report won’t be light reading, but Report Reader can help. Report Reader provides definitions for the medical terminology in your report, making it easier for you to understand your results and feel informed and confident at your follow-up appointments.

You can also get personalized insights based on your report. MyCare Navigator spotlights follow-up suggestions and can help you determine the best questions to ask at your next appointment using the Ask My Doctor feature. You’ll always arrive ready to participate in your care at your next prenatal appointment.

Feel confident and in control of your pregnancy

Pregnancy is often an exciting time but can feel nerve-wracking because many of the changes happening to your body are outside of your control. What you do have control over is understanding how your pregnancy progresses, including a better understanding of the medical acronyms and terminology in your ultrasound report.

Gaining knowledge of the medical terms in your report and understanding what your ultrasound images are capturing can ease any anxieties you might have about your baby’s growth, their health and your own wellbeing. More importantly, the knowledge you acquire also allows you to feel more informed and confident throughout your pregnancy when speaking with any member of your healthcare team.

How PocketHealth works

Learn more about how you can use PocketHealth to access and share your pregnancy ultrasound images and results.

Related Posts

Magnetic Resonance Spectroscopy

A Patient’s Guide to Magnetic Resonance Spectroscopy

June 4, 2024

How to Read an Ultrasound Picture

5 Tips on How to Better Understand an Ultrasound Picture

May 16, 2024

Global News announces PocketHealth Basic

Global News features PocketHealth Basic: Free access to medical imaging records

May 1, 2024

presentation in ultrasound report

drlogy

  • Download Drlogy App
  • Health Updates
  • Fitness & Health Calculator
  • Medical Abbreviations
  • Medical Dictionary
  • Drlogy Plus

Pathology Lab

  • Pathology Lab Software
  • Radiology Software
  • Hospital Management Software
  • Clinic Software
  • Dental Clinic Software
  • Ophthalmology Software
  • Pharmacy Software
  • Drlogy Letterhead
  • Pathology Lab Letterhead
  • Doctor Letterhead
  • Hospital Letterhead
  • Eye Hospital Letterhead
  • Clinic Letterhead
  • Dental Clinic Letterhead
  • Drlogy Free Listing
  • Free Doctor Listing
  • Free Hospital Listing
  • Free Clinic Listing
  • Free Lab Listing
  • Free Pharmacy Listing
  • Drlogy Education
  • Drlogy Plus Academy
  • Drlogy Report Format
  • SMART Report
  • Drlogy Test
  • Drlogy Calculator
  • Medical Abbreviation
  • Drlogy Plus Pathology Lab
  • Lab Letterhead
  • Free Pathology Lab Listing
  • Lab Brochure
  • Lab Modules
  • SMART Report Software
  • QR Code Report Software
  • Lab Billing Software
  • Reference Doctor Portal Software
  • Patient Portal Software
  • Phlebo Collection Software
  • Lab Report Format
  • Pathology Lab Report Format
  • CBC Report Format
  • Blood Test Report Format
  • Hematology Report Format
  • Biochemistry Report Format
  • Clinical Pathology Report Format
  • Immunology Report Format
  • Lab Test Report Format
  • Lab Growth & Future Trends
  • Pathology Lab Setup
  • Pathology Lab Growth
  • Pathology Lab Management
  • Pathology Lab Finance
  • Pathology Lab Staff
  • Pathology Lab Marketing
  • Patient Management
  • Drlogy Plus Radiology
  • Radiology Letterhead
  • Free Radiology Center Listing
  • Radiology Report Format
  • Radiology Brochure
  • Radiology Modules
  • X-Ray Software
  • Sonography or Ultrasound Reporting Software
  • CT Scan Software
  • MRI Software
  • X Ray Report Format
  • Ultrasound Report Format
  • CT Scan Report Format
  • MRI Scan Report Format
  • Brain Report Format
  • Knee Report Format
  • Chest Report Format
  • Radiology Future Trends
  • Radiology Center Setup
  • Radiology Center Growth
  • Radiology Center Management
  • Radiology Center Finance
  • Radiology Center Staff
  • Radiology Center Marketing
  • Drlogy Plus Hospital
  • Hospital Management Software (HMS)
  • Hospital Billing Software
  • Hospital Brochure
  • OPD Software
  • IPD Software
  • ICU Software
  • OT Software
  • Pathology Software
  • EHR Software
  • EMR Software
  • Billing Software
  • MRD Management Software
  • Ambulance Software
  • Biomedical Waste Software
  • Hospital Management
  • Hospital Management System
  • Hospital Staff
  • Hospital Finance
  • Patient Feedback
  • Patient Retention
  • Patient Service
  • Hospital Growth & Future Trends
  • Hospital Growth
  • Hospital Branding
  • Hospital Marketing
  • Hospital Setup
  • Drlogy Plus Clinic
  • Eye Clinic Software
  • Clinic Brochure
  • Dental Clinic Brochure
  • Ophthalmology Brochure
  • Clinic Modules
  • Bio Medical Waste Management
  • Clinic Management
  • Clinic Staff
  • Clinic Finance
  • Clinic Growth & Future Trends
  • Clinic Growth
  • Clinic Branding
  • Clinic Marketing
  • Clinic Setup

The 10 Clinical Guidelines for the Perfect Ultrasound Report Format

Healthcare organization

  • The 10 Clinical Guidelines for the Perfect Ultrasound Report Format

Introduction

Ultrasound reports play a pivotal role in modern medical practice. A well-structured ultrasound report is not just a formality; it serves as a vital communication tool between medical professionals and aids in accurate diagnosis and treatment.

In the context of India's diverse healthcare landscape, understanding the elements of an effective ultrasound report format is crucial for optimizing patient care.

Recommended Best Ultrasound Reporting Software in India

10 Key Clinical Guidelines for an Effective Ultrasound Report Format

1. patient information and identification.

  • Accurate patient information is the foundation of any medical report.
  • Including the patient's full name, age, gender, and unique identification numbers ensures that the report is associated with the correct individual.
  • In a country as populous as India, where names and identities can be common, precision in patient identification is paramount.

2. Clinical Indication

  • The clinical reason for performing the ultrasound provides essential context for interpreting the findings.
  • Linking the clinical information to the ultrasound report assists radiologists and referring doctors in making informed decisions.
  • This is particularly important in a country where a wide range of medical conditions are encountered.

3. Ultrasound Imaging Technique

  • The ultrasound technique used (2D, 3D, Doppler, etc.) should be clearly stated.
  • Different techniques provide varying levels of detail and functionality.
  • Specifying the technique ensures that the interpreting physician understands the nature of the images presented.

4. Anatomical Description

  • Precise anatomical descriptions of the organs or areas scanned are essential.
  • Using standardized medical terminology ensures consistency and facilitates effective communication.
  • This is particularly important in a culturally diverse country like India, where multiple languages and medical terminology can coexist.

5. Findings and Observations

  • At the core of the ultrasound report, this section presents the actual findings.
  • Abnormalities, measurements, and structures of interest should be described comprehensively.
  • In India, where a vast array of medical conditions is encountered, clear and detailed findings aid in accurate diagnoses.

6. Comparison with Previous Scans

  • If prior scans are available for comparison, noting changes or developments since the last scan is invaluable.
  • This longitudinal perspective is especially relevant in chronic conditions and during pregnancy, enhancing the understanding of disease progression.

7. Clinical Correlation

  • The ultrasound findings should be correlated with the patient's clinical symptoms or condition.
  • This bridges the gap between imaging and medical evaluation, leading to more precise diagnoses.
  • In India's complex healthcare landscape, where patients may present with diverse symptoms, clinical correlation is essential.

8. Conclusion and Impressions

  • Summarizing the overall assessment of the ultrasound findings, this section provides clarity on the radiologist's impressions.
  • Clearly stating whether the findings are normal or abnormal helps referring doctors understand the severity of the condition.

9. Recommendations

  • Providing guidance on follow-up tests, additional imaging, or specialist consultations is vital for patient care.
  • India's diverse healthcare facilities mean that the appropriate recommendations can vary widely based on location and available resources.

10. Visual Aids in Ultrasound Reports

  • Incorporating well-labeled images directly into the report enhances its comprehensibility.
  • Annotations can highlight specific structures or areas of interest, aiding referring physicians in understanding the findings quickly and accurately.

Best Ultrasound Report Format

Ultrasound Report Format - Drlogy

Benefits of a Well-Structured Ultrasound Report

  • Effective Communication: A standardized format facilitates clear communication between radiologists and referring physicians, leading to better patient care.
  • Accurate Diagnoses: Comprehensive reports contribute to accurate diagnoses, particularly relevant in a country with a high prevalence of various medical conditions.
  • Legal and Ethical Considerations: Thorough reports fulfill legal and ethical obligations, ensuring a complete medical record is maintained.

Regional Preferences and Norms in India

In a country as vast and diverse as India, there might be regional preferences or norms for ultrasound reporting. It's essential for medical professionals to be aware of and adhere to any local guidelines or preferences.

Technology and Innovation in Ultrasound Reporting

Advancements in technology have led to digital reporting systems and cloud-based solutions like Drlogy Ultrasounding Report Software . These innovations streamline the reporting process, making it more efficient and accessible, even in remote parts of India.

Conclusion In conclusion, a well-structured ultrasound report format is a cornerstone of effective medical practice in India. Adhering to standardized reporting practices ensures accurate diagnosis and optimal patient care, transcending the rich diversity of India's healthcare landscape.

Email Subsciption

Request Free Ultrasound Reporting Software Demo

Why Patient Followup Feature Must In IPD Software

Why Patient Followup Feature Must In IPD Software

favorite  Likes

Why Patient Billing Feature Must In IPD Software

Why Patient Billing Feature Must In IPD Software

Why Patient Discharge Feature Must In IPD Software

Why Patient Discharge Feature Must In IPD Software

Why Patient Management Feature Must In IPD Software

Why Patient Management Feature Must In IPD Software

Why Patient Education Feature Must In IPD Software

Why Patient Education Feature Must In IPD Software

Top baby names, ultrasound reporting software, ultrasound report format.

  • Why Data Security Must For Ultrasound Reporting Software Features
  • 14 Best Sonography or Ultrasound Reporting Software Features
  • Why Form F Must For Ultrasound Reporting Software Features
  • Why Patient Reporting Management Must For Ultrasound Reporting Software Features
  • Why Reference Doctor Sharing Must For Ultrasound Reporting Software
  • Why USG Report Format Must For Ultrasound Reporting Software Features
  • Why Consent Form Feature Must For Ultrasound Reporting Software Features
  • Why Billing Feature Must For Ultrasound Reporting Software Features
  • Why Mobile App Feature Must For Ultrasound Reporting Software Features
  • Why Good Customer Service Must For Ultrasound Reporting Software

Pathology lab Software

  • 14 Steps Pathology Lab Software Buying Guide For LIMS
  • Pathology Lab Marketing: 14 Steps Guide For Lab Advertisement
  • 8 Series Guide on How to Choose Right Biochemistry Analyzer
  • 14 Best Step by Step Guide For Pathology Lab Growth Strategies in India
  • 8 Series Guide on How To Choose Right Urine Analyzer For Labs
  • Step by Step Pathology Lab Setup Guide in India For New Lab Owners
  • Pathology Lab Test List: 1000+ Laboratory Test Directory A-Z
  • 8 Series Guide on How to Choose Right Hematology Analyzer For Your Lab
  • Pathology Lab Equipment List Guide For Every Lab Owners
  • Don't Buy LIMS Without These 14 Pathology Lab Software Features
  • 14 Best Hospital Growth Strategies With Step by Step Guide
  • 7 Steps Quick Guide on Hospital Revenue Cycle Management
  • 14 Best Step by Step Guide For Patient Care Management Strategies
  • 7 Quick Guides to Patient Scheduling System
  • 7 Quick Guides to Doctor Reputation Management
  • Don't Buy HMIS Without These 16 Hospital Management System Features
  • 7 Steps Quick Guide on No-Show Appointments
  • Don't Buy OPD Software Without These 14 Features For OPD Management
  • 14 Steps Guide For Hospital Marketing Strategies & Advertisement
  • 14 Best Patient Counselling Steps Guide in Healthcare

Dental Software

  • 14 Best Step by Step Guide For Dental Practice Growth Strategies
  • Key Importance of Software For Dental Practice Growth
  • 10 Best Branding Ideas For Dental Practice Growth in India
  • 10 Best Marketing Ideas For Dental Practice Growth in India
  • 10 Technology that will shape Dental Practice Growth
  • 10 Main Importance of Patient Education for Dental Practice Growth
  • 10 Essential Staff Training Strategies For Dental Practice Growth
  • Patient Feedback Importance For Dental Practice Growth
  • Patient Followup Importance For Dental Practice Growth
  • 10 Tips For Running A Successful Dental Clinic Practice in 2024
  • Top 10 Reasons to Choose OPD-IPD Software for Hospital/Clinic
  • 10 Key Tips for Eye Hospital Letterhead Design & Format
  • 10 Things to Look Out Before Choosing Ophthalmology Software
  • Top 10 Advantages Your Ophthalmology EHR Software Must Provide To Eye Clinic
  • 10 Reasons How to Choose the Right Clinic Software For Patient Growth
  • 10 Key Tips for Doctor Letterhead Design with Templates
  • What is Clinic Management System and Why it is Important?
  • 10 Ways to Improve Your Clinic Management System in India
  • 10 Key Tips for Clinic Letterhead Design with Templates
  • 7 Ways To Reduce Waiting Time in Your Practice With Clinic Software
  • 10 Ways To Increase Productivity of Clinic Using Clinic Software
  • 10 Ways To Improve Clinic Management System (CMS) Practices
  • Top 51 Benefits of using Clinic Management Software
  • 11 Benefits of Clinic Listing: Patient Growth With More Revanue

presentation in ultrasound report

Drlogy Hospital Management Software

Powerful Hospital Management system includes OPD, IPD, ICU, OT, Labs, Pharmacy, Store, Inventory, MRD, Billing, Patient Portal, Online Appointments, Telehealth & other 30 Modules to manage small to large scale Hospitals.

Pathology Lab Software - Drlogy

Drlogy Pathology Lab Software

Drlogy Pathology Software is a Complete Pathology Lab & Diagnostic Management system, with AI-based integrated information system design to manage the Medical Imaging Centers, Medical Laboratories & Pathology Centers.

Clinic Management Software -  Drlogy

Drlogy Clinic Management Software

Drlogy Clinic SaaS helps to speed up & digitize every process of medical practice including the history, e-prescriptions, investigation, procedures, billing, etc. without compromising the accuracy & improve the patient experience.

Dental Software - Drlogy

Drlogy Dental Software

Dental Dental Software (Dental SaaS) is an advanced AI-based powerful affordable Dental Clinic Software that helps Dentist to improve the efficiency of a clinic with good patient satisfaction.

Ophthalmology Software - Drlogy

Drlogy Ophthalmology Software

Drlogy Ophthalmology EHR Software specifically designed for Ophthalmology Practices, advanced AI-based solutions help to early detection of eyes medical conditions & enhance the patient experience.

DOCTOR’S MOST TRUSTED HEALTHCARE PLATFORM

Hospitals/Labs

Drlogy Plus Academy close

  • HealthPlus Author

Get Health Newsletter

Get A Free Software Demo !

  • Drlogy Healthcare Software
  • Drlogy Free Profile Listing
  • Doctor Listing
  • Pathology Lab Listing
  • Hospital Listing
  • Clinic Listing
  • Pharmacy Listing
  • Radiology Center Listing
  • Drlogy Health Day
  • Keep in touch

Loading metrics

Open Access

Peer-reviewed

Research Article

Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study

Contributed equally to this work with: Samantha Knights, Smriti Prasad

Roles Data curation

Affiliation Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom

Roles Conceptualization, Data curation, Writing – original draft, Writing – review & editing

Affiliation Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom

ORCID logo

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey, Department of Obstetrics and Gynaecology, Koc University, School of Medicine, Istanbul, Turkey

Roles Conceptualization

Roles Conceptualization, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom, Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom, Fetal Medicine Unit, Liverpool Women’s Hospital, Liverpool, United Kingdom

  • Samantha Knights, 
  • Smriti Prasad, 
  • Erkan Kalafat, 
  • Anahita Dadali, 
  • Pam Sizer, 
  • Francoise Harlow, 
  • Asma Khalil

PLOS

  • Published: April 6, 2023
  • https://doi.org/10.1371/journal.pmed.1004192
  • Peer Review
  • Reader Comments

Table 1

Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes.

Methods and findings

This was a retrospective multicentre cohort study where we included data from St. George’s (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0).

Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening ( p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening ( p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period.

Conclusions

In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.

Author summary

Why was this study done.

  • Accurate knowledge of fetal presentation is essential for optimal care during pregnancy and birth. Vaginal breech delivery is associated with adverse maternal and perinatal outcomes.
  • Abdominal palpation has poor sensitivity (50% to 70%) for determination of fetal presentation.
  • The role of a routine third ultrasound assessment of fetal presentation has been reported but the impact on neonatal outcomes is yet to be determined.
  • There are limited reports on antenatal use of handheld point-of-care ultrasound (POCUS) for the determination of fetal presentation, but the impact of their systematic use for this purpose is largely unknown.

What did the researchers do and find?

  • We analysed 2 cohorts of pregnant women from 2 large teaching hospitals in the United Kingdom where a policy of routine third trimester ultrasound or POCUS has been implemented.
  • We studied the impact of routine third trimester ultrasound or POCUS on the percentage of all term breech presentations that were undiagnosed and adverse neonatal outcomes, in pre- and post-screening epochs.
  • Due to the rarity of adverse outcomes, we employed Bayesian regression analysis with informative priors. This statistical tool permits updating previous findings with new data to generate new evidence.
  • We found that the incidence of all term breech presentations that were undiagnosed reduced drastically in the post-screening epoch following the implementation of either a third trimester ultrasound (decreased from 14.2% to 2.8%) or POCUS (decreased from 16.2% to 3.5%). There was an associated improvement in neonatal outcomes.

What do these findings mean?

  • Our findings imply that a policy of either a third trimester ultrasound by sonographers or POCUS by trained midwives was effective in reducing the proportion of all term breech presentations at the time of birth that were undiagnosed and associated neonatal complications.
  • Cost-effectiveness of POCUS needs to be explored further for feasibility of implementation on a wider scale for assessment of fetal presentation at term.

Citation: Knights S, Prasad S, Kalafat E, Dadali A, Sizer P, Harlow F, et al. (2023) Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med 20(4): e1004192. https://doi.org/10.1371/journal.pmed.1004192

Received: August 19, 2022; Accepted: February 7, 2023; Published: April 6, 2023

Copyright: © 2023 Knights et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because consent was not obtained from women; permission for sharing data was not sought as part of ethical approval. Data is only available following approval from Research Ethics Committee and Confidentiality Advisory Group. Enquiries and requests should be made to the the Research Governance and Delivery team at St George's University of London ( [email protected] ).

Funding: The author(s) received no specific funding for this work.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: AK is a Vice President of the Royal College of Obstetricians and Gynaecologists. AK is a Trustee (and the Treasurer) of the International Society of Ultrasound in Obstetrics and Gynecology AK has lectured at and consulted in several ultrasound-based projects, webinars and educational events.

Abbreviations: BAME, black, Asian, and minority ethnic; BMI, body mass index; CrI, credible intervals; ECV, external cephalic version; HIE, hypoxic ischemic encephalopathy; HRA, Health Research Authority; HTA, Health Technology Assessment; IMD, index of multiple deprivation; NICE, National Institute for Health and Care Excellence; NIHR, National Institute for Health Research; NNU, neonatal unit; NNUH, Norfolk and Norwich University Hospital; NSC, National Screening Committee; POCUS, point-of-care ultrasound; RR, risk ratio; SGH, St. George’s Hospital

Introduction

The incidence of breech presentation at term is 3% to 4% [ 1 ]. Breech vaginal birth is associated with an increase in both perinatal mortality and morbidity as well as maternal morbidity [ 2 – 7 ]. Correct knowledge of fetal presentation at term is essential for providing optimum antepartum and intrapartum care. Women with breech presentation at term can be effectively counselled about their options—external cephalic version (ECV), planned vaginal birth, or elective cesarean birth—with their inherent risks and perceived benefits [ 1 ]. There is substantial evidence that clinical examination is not accurate enough for determination of fetal presentation, with unacceptably high rates of missed breech/noncephalic presentations at term [ 8 , 9 ].

There are 2 modalities to screen for fetal presentation at term, each with its advantages and disadvantages: routine third trimester ultrasound or point-of-care/portable ultrasound (POCUS). Currently, routine third trimester ultrasound is not recommended by the United Kingdom National Institute for Health and Care Excellence (NICE) in low-risk pregnancies due to insufficient clinical and cost-effectiveness evidence [ 10 , 11 ]. In the UK, the current practice is to perform an early pregnancy risk assessment followed by referral pathways for low-risk and high-risk women. These risks relate to maternal, fetal, and placental pathology but are unrelated to the risk of breech presentation at term. Women deemed to be at high risk are referred for an ultrasound scan at 28 weeks’ gestation for fetal biometry with or without additional follow-up ultrasound scans. Low-risk women are followed up with clinical assessment (serial measurement of symphysio-fundal height) and referred for third trimester ultrasound if fetal growth restriction is suspected or if it is difficult to perform clinical examination, as in women with high body mass index (BMI), multiple pregnancy, or multiple uterine fibroids, or there is clinical suspicion of noncephalic fetal presentation at term [ 12 – 14 ]. Emerging data from observational studies and a systematic review indicate that it is feasible to accurately diagnose fetal presentation at term by third trimester ultrasound, thereby reducing the proportion of all term breech presentations that were undiagnosed at the time of labour and birth [ 15 – 18 ]. The clinical end point of any study of the diagnosis of breech presentation at term would be an improvement in neonatal outcomes, associated with reduction in incidence of undiagnosed breech. Hitherto published literature, however, could not demonstrate a translation of increased antenatal diagnosis of breech presentation into a statistically significant improvement in neonatal outcomes, most likely owing to the rarity of adverse outcomes.

Most of the data on the use of POCUS in antenatal settings are from low-resource settings where there is inadequate access to ultrasound owing to both material and physical constraints; hence, the focus is on task-shifting of obstetric ultrasound from sonographers to primary care providers [ 19 , 20 ]. A recently published review reported improved diagnostic accuracy with POCUS compared to clinical examination only, for high-risk obstetric conditions including fetal malpresentation, albeit studies were heterogeneous and referred to varying standards [ 21 ]. The Society of Obstetricians and Gynaecologists of Canada identifies POCUS as a useful modality for timely determination of fetal presentation [ 22 ]. A retrospective criterion-based audit performed in one of our study hospitals demonstrated that the use of POCUS by midwives in the antenatal ward/labour ward was associated with identification of previously unrecognized breech presentation, thereby preventing inappropriate induction of labour [ 23 ]. A recent validation study of POCUS in obstetric care showed near perfect agreement for assessment of fetal presentation [95.6% agreement, Kappa −0.887, 95% CI (0.78 to 0.99)] when compared to routine ultrasound [ 24 ]. There is, however, scanty literature on the diagnostic accuracy of POCUS in antenatal care settings for assessment of fetal presentation, compared to standard antenatal care, i.e., routine abdominal palpation, with referral for ultrasound when there is clinical suspicion of breech presentation.

In our study, we aimed to compare the impact of routine third trimester ultrasound or POCUS with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes.

The study included data from St. George’s University Hospital NHS Foundation Trust (SGH) and Norfolk and Norwich University Hospital NHS Foundation Trust (NNUH). For both centres, pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH).

Routine third trimester scan cohort

We included a cohort of pregnant women who gave birth between 4 April 2016 and 30 September 2021, at SGH, a large teaching hospital in South West London. The chosen starting point was the date when birth records were first systematically entered into the current electronic database. At SGH, a policy of routine third trimester (at 36 weeks) ultrasound scan by sonographers for all pregnant women has been implemented since January 2020; this includes assessment of fetal biometry, umbilical and middle cerebral artery Doppler, placental localization, amniotic fluid volume, and fetal presentation. Following a diagnosis of breech presentation during the ultrasound scan, women are counselled about their options: ECV, planned cesarean birth, or planned vaginal birth. If women declined ECV or if it was unsuccessful, they were offered elective cesarean delivery from 39 weeks of gestation. The population was divided into 2 study groups: Group 1 (women who were offered and accepted a routine third trimester scan) and Group 2 (women who received standard antenatal care in line with national guidance, without a routine third trimester scan).

POCUS cohort

The POCUS cohort included pregnant women from NNUH where a policy of routine POCUS at the 36-week antenatal visit was fully adopted from November 2020 following stage-wise implementation in 2016. The POCUS is performed by a midwife using Vscan Air (GE Healthcare). NNUH is a large teaching hospital with approximately 6,000 births per year, and approximately 250 midwives working across the hospital and community. We included 2 groups: a historical cohort of women who received routine care—abdominal palpation and referral for selective ultrasound on clinical suspicion of breech presentation (2015) and those who had POCUS at the 36- to 37-week visit (November 2020 to 2021). Through 2016 to November 2020, POCUS was variably used, either on the labour ward or via referral from community midwives, on clinical suspicion of noncephalic presentation, and these women were not included in this study.

Training of midwives for POCUS cohort

The midwives in NNUH underwent a structured 3-month training programme. The workshops consisted of daily handheld scanning sessions with an hour of dedicated lectures. The theoretical lectures were followed by practice on consenting women in the antenatal ward. All the trainee midwives maintained a competency logbook, detailing both successful and unsuccessful cases. Following the initial workshops, “midwife champions” were identified who were deemed competent or held other ultrasound qualifications and were suitable for cascade training. POCUS training was a part of preceptor ship training of newly qualified midwives, while midwives working in nonpermanent roles were supported and advised to work with one of the champions.

The primary outcome was the proportion of all term breech presentations that were undiagnosed. Undiagnosed breech presentation was defined as follows: (a) breech presentation after the onset of labour or rupture of membranes at term; and (b) breech presentation diagnosed immediately before commencing induction of labour. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE) 1 to 3, and perinatal mortality (includes stillbirths and early neonatal deaths).

Women with multiple pregnancies, preterm birth <37 weeks, and congenital abnormalities were excluded. Pregnancies undergoing planned cesarean section for breech presentation were excluded from the analysis of the study outcomes, except for the neonatal outcomes. Maternal demographic characteristics, antenatal, intrapartum, and perinatal data were extracted from Euroking E3 maternity information system and Viewpoint database (ViewPoint 5.6.8.428, ViewPoint Bildverarbeitung GmbH, Weßling, Germany). Routinely collected clinical data were collated from electronic health records and were deemed not to require ethics approval or signed patient consent as per the Health Research Authority (HRA) decision tool.

Statistical analysis

Descriptive variables were compared with Wilcoxon-signed rank test, t test, or chi-squared test, where appropriate. An adequately powered analysis is not practically feasible due to rarity of adverse outcomes following breech delivery. Therefore, we employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood) [ 18 ]. The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models and reported as RR (risk ratios) with credible intervals (CrI). Informative priors ( N ~ μ, σ ) for population mean were derived from Salim and colleagues and a weakly informative prior (Student t , df = 3) for model intercept. Prior parameters were estimated by using the log-risk ratios and log-confidence intervals from Salim and colleagues, and in case an effect could not be estimated in the original study due to a no-event situation, we added a single event to the corresponding group and reestimated the risk ratios. Two Markov chains were run for 1,500 iterations after an initial 500 burn-in period. Posterior probabilities were calculated using the probability density function of normal distribution. A sensitivity analysis using flat priors (noninformative) was also undertaken to investigate the weight of informative prior on the posterior density. Number needed to treat for important outcomes was calculated using current population numbers without incorporating external data. Convergence was checked with trace plots. All analyses were conducted using R for Statistical Software (v.4.2.0) using “brms” and “its.analysis” packages [ 25 , 26 ]. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline ( S1 STROBE Checklist).

Study cohorts

In the SGH cohort, there were 24,128 singleton pregnancies during the eligibility period, of which 16,777 births were before the introduction of universal third trimester ultrasound scan and 7,351 after. Baseline characteristics of included pregnancies are presented in Table 1 . Women who gave birth before universal ultrasound scan were significantly younger (33.2 versus 35.7 years, p < 0.001), had similar BMI (25.6 versus 25.7 kg/m 2 , p = 0.194) and multiparity rate (49.6% [8,316/16,777] versus 49.2% [3,617/7,351], p = 0.612) compared to those who gave birth after. There was a slight drop in the proportion of births that were in women from black, Asian, and minority ethnic (BAME) background (39.3% [6,588/16,777] versus 37.9% [2,785/7,351], p = 0.044). The index of multiple deprivation (IMD) quintiles were similar between the 2 epochs ( p > 0.05 for all quintiles; Table 1 ), as was the total number of breech presentations at the time of birth (3.4% [578/16,777] versus 3.4% [251/7,351], p = 0.953), including all diagnosed and undiagnosed cases. A comparison of the baseline characteristics, as well as the gestational age at delivery in weeks and mode of birth of pregnancies with breech presentation at birth in the study epochs before and after the introduction of universal 36-week ultrasound scan is shown in Table 2 . Pregnancies with breech presentation at term were significantly more likely to be delivered by elective cesarean section (76.9% [193/251] versus 60.7% [351/278], p < 0.001) after compared to before the implementation of the universal 36-week ultrasound scan. Emergency cesarean section was lower (17.1% [43/251] versus 30.8% [178/578], p < 0.001) after compared to before the implementation of the universal 36-week ultrasound scan. A similar trend was noted for vaginal breech delivery ( Table 2 ). The gestational age at birth was 39.1 weeks in both groups with a mean difference of 1 day. Although the difference was statistically significant, it would be deemed clinically inconsequential.

thumbnail

  • PPT PowerPoint slide
  • PNG larger image
  • TIFF original image

https://doi.org/10.1371/journal.pmed.1004192.t001

thumbnail

https://doi.org/10.1371/journal.pmed.1004192.t002

The percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before and 2.8% (7/251) after the implementation of universal screening ( p < 0.001) ( Table 3 ). The rate of elective cesarean delivery was higher during the universal scan epoch (13.0% [959/7,351] versus 12.0% [2,019/16,777], p = 0.029), while the emergency cesarean rate was lower (12.9% [2,169/16,777] versus 11.5% [845/7,351], p = 0.029) compared to the previous epoch. The total number of vaginal breech births reduced from 29 per 10,000 births to 20 per 10,000 births, but this difference did not reach statistical significance ( p = 0.276). A regression discontinuity (interrupted time series) analysis showed significant variation in the number of undiagnosed breech presentations between 2 epochs (before and after universal ultrasound, p < 0.001) ( Fig 1 ).

thumbnail

Dotted line represents the fitted regression curve with splines.

https://doi.org/10.1371/journal.pmed.1004192.g001

thumbnail

https://doi.org/10.1371/journal.pmed.1004192.t003

In the NNUH cohort, there were 9,694 singleton births during the eligibility period, of which 5,119 births were before the initiation of POCUS screening and 4,575 births after the complete implementation of POCUS. Women who gave birth before POCUS were significantly older (34.6 versus 31.6 years, p < 0.001) and had a lower BMI (25.6 versus 26.5 kg/m 2 , p < 0.001) than those who gave birth after. The percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before and 3.5% (5/142) after the implementation of universal POCUS screening ( p < 0.001) ( Table 4 ).

thumbnail

https://doi.org/10.1371/journal.pmed.1004192.t004

Perinatal outcomes

We analysed the SGH cohort using Bayesian regression analysis with both flat (noninformative) and informative priors (Using data from Salim and colleagues) [ 18 ]. Regression with informative priors showed the percentage of all term breech presentations that were undiagnosed was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9% ( Table 3 ). Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Analysis using flat priors (noninformative) also showed that the percentage of all term breech presentations that were undiagnosed was 74% lower (RR, 0.26; 95% CrI 0.10, 0.59) with very high posterior probability of 99.8%. The reduction in low Apgar scores was also observed in flat prior analysis that corresponded to a 65% reduction (RR, 0.35; 95% CrI 0.06, 1.42) with a moderate to high probability (89.8%). The number needed to scan to prevent one case of undiagnosed breech presentation was 255 (95% CI: 192 to 376).

We analysed the NNUH cohort using the same methods. Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9% ( Table 4 ). There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). Flat prior analysis also showed that undiagnosed breech presentation was lower by 80% (RR, 0.20; 95% CrI: 0.07, 0.51) with very high posterior probability of 99.9%. No inference could be made for HIE or extended perinatal mortality as there were no events in either period.

In our study, use of a policy of either routine third trimester scan or routine third trimester POCUS was associated with a significant reduction in the proportion of all breech presentations that were undiagnosed at term, when compared to standard antenatal care. Short-term adverse perinatal outcomes, including NNU admission and low Apgar scores, were significantly lower for the pregnancies with diagnosed breech presentation at term following a policy for screening by either routine third trimester scan or POCUS. Previous studies were unable to study perinatal outcomes due to their small numbers.

Our cohorts are derived from real-world data from 2 large teaching hospitals in the UK. Much of the previously reported literature on use of third trimester ultrasound for diagnosis of breech presentation is from research settings with a dedicated breech clinic and available expertise and skills for manoeuvres like ECV and vaginal breech births. Conclusions from research settings may not be generalizable to clinical settings and may be prone to bias. Furthermore, our study is the first to compare the impact of POCUS with routine antenatal care for diagnosis of fetal presentation. Routine ultrasound scan is effective at reducing the proportion of all term breech presentations that were undiagnosed, but the clinical impact of this change is hard to assess owing to the rarity of adverse outcomes [ 18 ]. We employed a Bayesian approach using both informative priors from similar studies and flat priors as a sensitivity analysis that allowed us to estimate the effect of universal ultrasound in probabilistic terms without depending on P values.

There are some limitations to our study. Firstly, we did not have reliable data on ECV for both our cohorts. The universal scan might have implications, not just for babies that were breech at birth (e.g., ECV could be performed, which could lead to not being breech and therefore not being included in the outcomes, or some other benefit, or indeed, theoretically, harm). Salim and colleagues included all babies diagnosed as breech. The method employed by Salim and colleagues also has drawbacks as it did not include those undiagnosed before the universal scan. Nevertheless, it is unlikely to have had a substantial impact on our results given the low acceptance and variable success rates. This is reflected in the almost identical incidence of overall (undiagnosed and diagnosed) breech presentation before and after screening. Salim and colleagues also reported no difference in the rates of overall breech presentations despite systematic use of ECV with acceptance rates of as high as 80% [ 18 ]. Secondly, the number of adverse neonatal outcomes such as extended perinatal mortality and HIE were not sufficient to estimate an effect in the NNUH cohort. Finally, the maternity records at NNUH were uploaded on electronic database only from April 2015. Therefore, reliable data on demographic parameters like BMI, ethnicity, and IMD were not available for the first quarter of 2015. These factors, however, are unlikely to influence the results.

Our findings of a reduction in the proportion of all term breech presentations that were undiagnosed at term after implementation of routine third trimester scan resonates with those of Salim and colleagues, who reported a reduction from 22.3% to 4.7% following the introduction of universal third trimester scan, compared to standard antenatal care [ 18 ]. Yet there are no published data from the UK on the impact of routine POCUS on the reduction of the percentage of all term breech presentations that were undiagnosed at term. Observational studies from Kenya [ 19 ], Uganda [ 27 ], and Guatemala [ 28 ] have reported that midwives who underwent focused basic obstetric ultrasound training for 3 to 8 weeks were able to identify fetal presentation with high sensitivity and specificity. The proportion of all term breech presentations that were undiagnosed at term, however, could not be eliminated in both cohorts, with 7 and 5 such cases in the routine third trimester scan and POCUS cohorts, respectively. Most of these cases were a consequence of spontaneous version to breech from cephalic presentation in multiparous women. Salim and colleagues also described spontaneous version to breech in multiparous women (76% of cases of undiagnosed breech) in their cohort. Wastlund and colleagues reported in their prospective cohort of 3,879 women that a policy of universal third trimester scan virtually eliminated undiagnosed breech presentations in labour [ 16 ]. It should, however, be noted that their cohort comprised of nulliparous women only in a strict research setting.

We also noted a significant improvement in short-term neonatal outcomes including low Apgar scores at 5 minutes and NNU admission. Salim and colleague demonstrated a nonsignificant improvement in short-term neonatal outcomes [ 18 ]. Although we were unable to demonstrate an effect on outcomes such as HIE and neonatal mortality, observational data from low-resource settings report a reduction in neonatal mortality when women were referred in a timely manner for fetal malpresentation [ 29 ].

Accurate knowledge of fetal presentation at term is crucial for optimal antenatal and intrapartum care. Both routine third trimester scan by a sonographer/clinician or use of POCUS by trained midwives can achieve this objective. Although evidence suggests that a planned breech vaginal birth may be offered after careful case selection and counselling, a large proportion of maternity units in the UK and worldwide lack skilled providers for vaginal breech births. Antenatal identification of breech presentation would allow healthcare providers to offer unbiased information such that pregnant women feel empowered to make an informed decision and have a positive birth experience. A meeting of the UK National Screening Committee (NSC) in March 2021 acknowledged that ultrasound for fetal presentation appears promising; however, the committee recommended that further work on screening for fetal presentation could not be commissioned at that time. The NSC agreed to add screening for fetal presentation to the recommendations list for reconsideration in 3 years’ time if significant evidence evolves in the interim [ 30 ]. Our findings add to that evidence base. A cost-effectiveness analysis study conducted in the UK showed that universal third trimester ultrasound would “virtually eliminate” the proportion of all term breech presentations that were undiagnosed and would be cost-effective if fetal presentation could be assessed at £19.80 pounds per woman or less [ 16 ]. A National Institute for Health Research (NIHR) Health Technology Assessment (HTA) review has suggested that handheld portable ultrasound can readily close this gap as a low-cost device that antenatal care providers like midwives could use for fetal presentation with minimal training [ 31 ]. The major obstacles to routine third trimester scan policy include the costs incurred, whereas a policy of using POCUS in community clinics and the labour ward by healthcare providers, after a short period of training, appears to be as effective as a policy of routine third trimester formal departmental ultrasound. Implementation of POCUS in the community for fetal presentation would also curtail indirect costs by reduction in referrals for facility-based ultrasound based on clinical suspicion, apart from also instilling a sense of empowerment among the care providers and satisfaction among pregnant women. The policy of POCUS was acceptable to pregnant women in our cohort who wanted to avoid nonessential hospital visits during the COVID-19 pandemic. A potential pitfall of the portable ultrasound cited when used in low-resource settings was dependence on internet coverage, which is unlikely to be a deterrent in the UK. Nonetheless, regular audits, ongoing training, and quality improvement measures should be in place to support community healthcare providers to ensure safe practice.

Our data suggest that a policy of either third trimester ultrasound or POCUS by healthcare providers could be effective in reducing the proportion of all term breech presentations that were undiagnosed at birth with an associated improvement in neonatal outcomes.

Supporting information

S1 strobe checklist. strobe checklist..

https://doi.org/10.1371/journal.pmed.1004192.s001

  • 1. Management of Breech Presentation (Green-top Guideline No. 20b) [Internet]. Royal College of Obstetricians & Gynaecologists. [cited 2022 May 1]. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20b/
  • View Article
  • PubMed/NCBI
  • Google Scholar
  • 10. Universal ultrasound in late pregnancy did not reduce serious harms to babies [Internet]. NIHR Evidence. [cited 2022 May 1]. Available from: https://evidence.nihr.ac.uk/alert/universal-ultrasound-in-late-pregnancy-did-not-reduce-serious-harms-to-babies/
  • 11. National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L [Internet]. London: National Institute for Health and Care Excellence (NICE); 2021 [cited 2022 May 1]. (NICE Evidence Reviews Collection). Available from: http://www.ncbi.nlm.nih.gov/books/NBK573936/
  • 12. Overview | Antenatal care | Guidance | NICE [Internet]. NICE; [cited 2022 May 1]. Available from: https://www.nice.org.uk/guidance/ng201
  • 13. Small-for-Gestational-Age Fetus, Investigation and Management (Green-top Guideline No. 31) [Internet]. Royal College of Obstetricians & Gynaecologists. [cited 2022 May 1]. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg31/
  • 14. Perinatal Institute: Programme [Internet]. [cited 2022 May 1]. Available from: https://www.perinatal.org.uk/GAP/programme
  • 23. British Journal of Midwifery—Detection of breech presentation: Abdominal palpation and hand-held scanning by midwives [Internet]. Br J Midwifery. [cited 2022 May 1]. Available from: https://www.britishjournalofmidwifery.com/articles/detection-of-breech-presentation-abdominal-palpation-and-hand-held-scanning-by-midwives/
  • 26. English P The its.analysis R Package–Modelling Short Time Series Data (June 6, 2019). Available from: https://ssrn.com/abstract=3398189 . https://doi.org/10.2139/ssrn.3398189
  • 30. UK NSC minutes March 2021 [Internet]. GOV.UK. [cited 2022 Jul 10]. Available from: https://www.gov.uk/government/publications/uk-nsc-meeting-march-2021/uk-nsc-minutes-march-2021
  • 31. 21/582 Point of care ultrasound for breech presentation at term commissioning brief [Internet]. [cited 2022 May 1]. Available from: https://www.nihr.ac.uk/documents/21582-point-of-care-ultrasound-for-breech-presentation-at-term-commissioning-brief/29207

The Ultrasound Journal Cover Image

Case Reports

We encourage the publication of original and interesting case reports that contribute significantly to medical knowledge. Manuscripts must meet one of the following criteria:

1. Unreported or unusual side effects or adverse interactions involving medications. 2. Unexpected or unusual presentations of a disease. 3. New associations or variations in disease processes. 4. Presentations, diagnoses and/or management of new and emerging diseases. 5. An unexpected association between diseases or symptoms. 6. An unexpected event in the course of observing or treating a patient. 7. Findings that shed new light on the possible pathogenesis of a disease or an adverse effect.

  • Case reports should include an up-to-date review of all previous cases in the field.
  • Authors should seek written and signed consent to publish the information from the patients or their guardians prior to submission. Authors will be asked to confirm informed consent was received as part of the submission process. The submitted manuscript must include a statement to this effect in the 'Consent' section, as follows: "Written informed consent was obtained from the patient for publication of this case report and accompanying images". The editorial office may request copies of the informed consent documentation upon submission of the manuscript.
  • Appropriate institutional review board (IRB) review and approval should accompany all studies involving human participants or research material derived from human participants. This information should be clearly stated in the Method section of the manuscript including the date of the IRB approval and duration of the trial/study.  If the study was exempted from IRB approval, that information should be indicated in the Method section.

Note to authors:  Regardless of below information, Case Report for Egyptian Journal of Neurosurgery should be divided into three sections;"Background", "Case presentation", and "Discussion". Please refrain from using  'Conclusion'. 

Preparing your manuscript

Title page 

The title page should:

  • "A versus B in the treatment of C: a randomized controlled trial", "X is a risk factor for Y: a case control study", "What is the impact of factor X on subject Y: A systematic review, A case report etc."
  • or, for non-clinical or non-research studies: a description of what the article reports
  • if a collaboration group should be listed as an author, please list the Group name as an author. If you would like the names of the individual members of the Group to be searchable through their individual PubMed records, please include this information in the “Acknowledgements” section in accordance with the instructions below
  • Large Language Models (LLMs), such as ChatGPT , do not currently satisfy our authorship criteria . Notably an attribution of authorship carries with it accountability for the work, which cannot be effectively applied to LLMs. Use of an LLM should be properly documented in the Methods section (and if a Methods section is not available, in a suitable alternative part) of the manuscript
  • indicate the corresponding author

The abstract should not exceed 350 words. Please minimize the use of abbreviations and do not cite references in the abstract. The abstract must include the following separate sections:

  • Background: why the case should be reported and its novelty
  • Case presentation: a brief description of the patient’s clinical and demographic details, the diagnosis, any interventions and the outcomes
  • Conclusions: a brief summary of the clinical impact or potential implications of the case report

Keywords 

Three to ten keywords representing the main content of the article.

The Background section should explain the background to the case report or study, its aims, a summary of the existing literature.

Case presentation

This section should include a description of the patient’s relevant demographic details, medical history, symptoms and signs, treatment or intervention, outcomes and any other significant details.

Conclusions

This should state clearly the main conclusions and include an explanation of their relevance or importance to the field.

List of abbreviations

If abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations should be provided.

Declarations

All manuscripts must contain the following sections under the heading 'Declarations':

Ethics approval and consent to participate

Consent for publication.

  • Availability of data and material

Competing interests

Authors' contributions, acknowledgements.

  • Authors' information (optional)

Please see below for details on the information to be included in these sections.

If any of the sections are not relevant to your manuscript, please include the heading and write 'Not applicable' for that section.

Manuscripts reporting studies involving human participants, human data or human tissue must:

  • include a statement on ethics approval and consent (even where the need for approval was waived)
  • include the name of the ethics committee that approved the study and the committee’s reference number if appropriate

Studies involving animals must include a statement on ethics approval.

See our  editorial policies  for more information.

If your manuscript does not report on or involve the use of any animal or human data or tissue, please state “Not applicable” in this section.

If your manuscript contains any individual person’s data in any form (including individual details, images or videos), consent to publish must be obtained from that person, or in the case of children, their parent or legal guardian. All presentations of case reports must have consent to publish.

You can use your institutional consent form if you prefer. You should not send the form to us on submission, but we may request to see a copy at any stage (including after publication).

See our  editorial policies  for more information on consent for publication.

If your manuscript does not contain data from any individual person, please state “Not applicable” in this section.

Availability of data and materials

All manuscripts must include an ‘Availability of data and materials’ statement. Data availability statements should include information on where data supporting the results reported in the article can be found including, where applicable, hyperlinks to publicly archived datasets analysed or generated during the study. By data we mean the minimal dataset that would be necessary to interpret, replicate and build upon the findings reported in the article. We recognise it is not always possible to share research data publicly, for instance when individual privacy could be compromised, and in such instances data availability should still be stated in the manuscript along with any conditions for access.

Data availability statements can take one of the following forms (or a combination of more than one if required for multiple datasets):

  • The datasets generated and/or analysed during the current study are available in the [NAME] repository, [PERSISTENT WEB LINK TO DATASETS]
  • The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
  • All data generated or analysed during this study are included in this published article [and its supplementary information files].
  • The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.
  • Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
  • The data that support the findings of this study are available from [third party name] but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [third party name].
  • Not applicable. If your manuscript does not contain any data, please state 'Not applicable' in this section.

More examples of template data availability statements, which include examples of openly available and restricted access datasets, are available  here .

SpringerOpen  also requires that authors cite any publicly available data on which the conclusions of the paper rely in the manuscript. Data citations should include a persistent identifier (such as a DOI) and should ideally be included in the reference list. Citations of datasets, when they appear in the reference list, should include the minimum information recommended by DataCite and follow journal style. Dataset identifiers including DOIs should be expressed as full URLs. For example:

Hao Z, AghaKouchak A, Nakhjiri N, Farahmand A. Global integrated drought monitoring and prediction system (GIDMaPS) data sets. figshare. 2014.  http://dx.doi.org/10.6084/m9.figshare.853801

With the corresponding text in the Availability of data and materials statement:

The datasets generated during and/or analysed during the current study are available in the [NAME] repository, [PERSISTENT WEB LINK TO DATASETS]. [Reference number]

All financial and non-financial competing interests must be declared in this section.

See our  editorial policies  for a full explanation of competing interests. If you are unsure whether you or any of your co-authors have a competing interest please contact the editorial office.

Please use the authors’ initials to refer to each authors' competing interests in this section.

If you do not have any competing interests, please state "The authors declare that they have no competing interests" in this section.

All sources of funding for the research reported should be declared. The role of the funding body in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript should be declared.

The individual contributions of authors to the manuscript should be specified in this section. Guidance and criteria for authorship can be found in our  editorial policies .

Please use initials to refer to each author's contribution in this section, for example: "FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript."

Please acknowledge anyone who contributed towards the article who does not meet the criteria for authorship including anyone who provided professional writing services or materials.

Authors should obtain permission to acknowledge from all those mentioned in the Acknowledgements section.

See our  editorial policies  for a full explanation of acknowledgements and authorship criteria.

If you do not have anyone to acknowledge, please write "Not applicable" in this section.

Group authorship (for manuscripts involving a collaboration group): if you would like the names of the individual members of a collaboration Group to be searchable through their individual PubMed records, please ensure that the title of the collaboration Group is included on the title page and in the submission system and also include collaborating author names as the last paragraph of the “Acknowledgements” section. Please add authors in the format First Name, Middle initial(s) (optional), Last Name. You can add institution or country information for each author if you wish, but this should be consistent across all authors.

Please note that individual names may not be present in the PubMed record at the time a published article is initially included in PubMed as it takes PubMed additional time to code this information.

Authors' information

This section is optional.

You may choose to use this section to include any relevant information about the author(s) that may aid the reader's interpretation of the article, and understand the standpoint of the author(s). This may include details about the authors' qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

Footnotes should be designated within the text using a superscript number. It is not allowed to use footnotes for references/citations.

Examples of the Basic Springer reference style are shown below. 

See our editorial policies for author guidance on good citation practice.

Web links and URLs: All web links and URLs, including links to the authors' own websites, should be given a reference number and included in the reference list rather than within the text of the manuscript. They should be provided in full, including both the title of the site and the URL, as well as the date the site was accessed, in the following format: The Mouse Tumor Biology Database. http://tumor.informatics.jax.org/mtbwi/index.do . Accessed 20 May 2013. If an author or group of authors can clearly be associated with a web link, such as for weblogs, then they should be included in the reference.

Example reference style:

Article within a journal

Smith J, Jones M Jr, Houghton L (1999) Future of health insurance. N Engl J Med 965:325-329.

Article by DOI (with page numbers)

Slifka MK, Whitton JL (2000) Clinical implications of dysregulated cytokine production. J Mol Med 78:74-80. doi:10.1007/s001090000086.

Article by DOI (before issue publication and with page numbers)

Slifka MK, Whitton JL (2000) Clinical implications of dysregulated cytokine production. J Mol Med. doi:10.1007/s001090000086.

Article in electronic journal by DOI (no paginated version)

Slifka MK, Whitton JL (2000) Clinical implications of dysregulated cytokine production. Dig J Mol Med. doi:10.1007/s801090000086.

Journal issue with issue editor

Smith J (ed) (1998) Rodent genes. Mod Genomics J 14(6):126-233.

Journal issue with no issue editor

Mod Genomics J (1998) Rodent genes. Mod Genomics J 14(6):126-233.

Book chapter, or an article within a book

Brown B, Aaron M (2001) The politics of nature. In: Smith J (ed) The rise of modern genomics, 3rd edn. Wiley, New York.

Complete book, authored

South J, Blass B (2001) The future of modern genomics. Blackwell, London.

Complete book, edited

Smith J, Brown B (eds) (2001) The demise of modern genomics. Blackwell, London.

Complete book, also showing a translated edition [Either edition may be listed first.]

Adorno TW (1966) Negative Dialektik. Suhrkamp, Frankfurt. English edition: Adorno TW (1973) Negative Dialectics (trans: Ashton EB). Routledge, London.

Chapter in a book in a series without volume titles

Schmidt H (1989) Testing results. In: Hutzinger O (ed) Handbook of environmental chemistry, vol 2E. Springer, Heidelberg, p 111.

Chapter in a book in a series with volume titles

Smith SE (1976) Neuromuscular blocking drugs in man. In: Zaimis E (ed) Neuromuscular junction. Handbook of experimental pharmacology, vol 42. Springer, Heidelberg, pp 593-660.

OnlineFirst chapter in a series (without a volume designation but with a DOI)

Saito, Yukio, and Hyuga, Hiroyuki. (2007) Rate equation approaches to amplification of enantiomeric excess and chiral symmetry breaking. Topics in Current Chemistry. doi:10.1007/128_2006_108.

Proceedings as a book (in a series and subseries)

Zowghi D (1996) A framework for reasoning about requirements in evolution. In: Foo N, Goebel R (eds) PRICAI'96: topics in artificial intelligence. 4th Pacific Rim conference on artificial intelligence, Cairns, August 1996. Lecture notes in computer science (Lecture notes in artificial intelligence), vol 1114. Springer, Heidelberg, p 157.

Article within conference proceedings with an editor (without a publisher)

Aaron M (1999) The future of genomics. In: Williams H (ed) Proceedings of the genomic researchers, Boston, 1999.

Article within conference proceedings without an editor (without a publisher)

Chung S-T, Morris RL (1978) Isolation and characterization of plasmid deoxyribonucleic acid from Streptomyces fradiae. In: Abstracts of the 3rd international symposium on the genetics of industrial microorganisms, University of Wisconsin, Madison, 4-9 June 1978.

Article presented at a conference

Chung S-T, Morris RL (1978) Isolation and characterization of plasmid deoxyribonucleic acid from Streptomyces fradiae. Paper presented at the 3rd international symposium on the genetics of industrial microorganisms, University of Wisconsin, Madison, 4-9 June 1978.

Norman LO (1998) Lightning rods. US Patent 4,379,752, 9 Sept 1998.

Dissertation

Trent JW (1975) Experimental acute renal failure. Dissertation, University of California.

Book with institutional author

International Anatomical Nomenclature Committee (1966) Nomina anatomica. Excerpta Medica, Amsterdam.

In press article

Major M (2007) Recent developments. In: Jones W (ed) Surgery today. Springer, Dordrecht (in press).  

Online document

Doe J (1999) Title of subordinate document. In: The dictionary of substances and their effects. Royal Society of Chemistry. Available via DIALOG. http://www.rsc.org/dose/title of subordinate document. Accessed 15 Jan 1999.

Online database

Healthwise Knowledgebase (1998) US Pharmacopeia, Rockville. http://www.healthwise.org. Accessed 21 Sept 1998.

Supplementary material/private homepage

Doe J (2000) Title of supplementary material. http://www.privatehomepage.com. Accessed 22 Feb 2000.

University site

Doe J (1999) Title of preprint. http://www.uni-heidelberg.de/mydata.html. Accessed 25 Dec 1999.

Doe J (1999) Trivial HTTP, RFC2169. ftp://ftp.isi.edu/in-notes/rfc2169.txt. Accessed 12 Nov 1999.

Organization site

ISSN International Centre (2006) The ISSN register. http://www.issn.org. Accessed 20 Feb 2007.

General formatting information

Manuscripts must be written in concise English. For help on scientific writing, or preparing your manuscript in English, please see Springer's  Author Academy .

Quick points:

  • Use double line spacing
  • Include line and page numbering
  • Use SI units: Please ensure that all special characters used are embedded in the text, otherwise they will be lost during conversion to PDF
  • Do not use page breaks in your manuscript

File formats

The following word processor file formats are acceptable for the main manuscript document:

  • Microsoft word (DOC, DOCX)
  • Rich text format (RTF)
  • TeX/LaTeX 

Please note: editable files are required for processing in production. If your manuscript contains any non-editable files (such as PDFs) you will be required to re-submit an editable file if your manuscript is accepted.

For more information, see ' Preparing figures ' below.

Additional information for TeX/LaTeX users

You are encouraged to use the Springer Nature LaTeX template when preparing a submission. A PDF of your manuscript files will be compiled during submission using pdfLaTeX and TexLive 2021. All relevant editable source files must be uploaded during the submission process. Failing to submit these source files will cause unnecessary delays in the production process.  

Style and language

For editors and reviewers to accurately assess the work presented in your manuscript you need to ensure the English language is of sufficient quality to be understood. If you need help with writing in English you should consider:

  • Getting a fast, free online grammar check .
  • Visiting the English language tutorial which covers the common mistakes when writing in English.
  • Asking a colleague who is proficient in English to review your manuscript for clarity.
  • Using a professional language editing service where editors will improve the English to ensure that your meaning is clear and identify problems that require your review. Two such services are provided by our affiliates Nature Research Editing Service and American Journal Experts . SpringerOpen authors are entitled to a 10% discount on their first submission to either of these services. To claim 10% off English editing from Nature Research Editing Service, click here . To claim 10% off American Journal Experts, click here .

Please note that the use of a language editing service is not a requirement for publication in The Ultrasound Journal and does not imply or guarantee that the article will be selected for peer review or accepted.  为便于编辑和评审专家准确评估您稿件中陈述的研究工作,您需要确保文稿英语语言质量足以令人理解。如果您需要英文写作方面的帮助,您可以考虑:

  • 获取快速、免费的在线  语法检查 。
  • 查看一些有关英语写作中常见语言错误的 教程 。
  • 请一位以英语为母语的同事审阅您的稿件是否表意清晰。
  • 使用专业语言编辑服务,编辑人员会对英语进行润色,以确保您的意思表达清晰,并提出需要您复核的问题。例如我们的附属机构 Nature Research Editing Service 以及合作伙伴 American Journal Experts 都可以提供此类专业服务。SpringerOpen作者享受首次订单10%优惠,该优惠同时适用于两家公司。您只需点击以下链接即可开始。使用 Nature Research Editing Service的编辑润色10%的优惠服务,请点击 这里 。使用 American Journal Experts的10%优惠服务,请点击 这里 。

请注意,使用语言编辑服务并非在期刊上发表文章的必要条件,这也并不意味或保证文章将被选中进行同行评议或被接受。 エディターと査読者があなたの論文を正しく評価するには、使用されている英語の質が十分であることが必要とされます。英語での論文執筆に際してサポートが必要な場合には、次のオプションがあります:

  • 高速なオンライン  文法チェック  を無料で受ける。
  • 英語で執筆する際のよくある間違いに関する 英語のチュートリアル を参照する。
  • 英語を母国語とする同僚に、原稿内の英語が明確であるかをチェックしてもらう。
  • プロの英文校正サービスを利用する。校正者が原稿の意味を明確にしたり、問題点を指摘し、英語を向上させます。 Nature Research Editing Service と American Journal Experts の2つは弊社と提携しているサービスです。SpringerOpenのジャーナルの著者は、いずれかのサービスを初めて利用する際に、10%の割引を受けることができます。Nature Research Editing Serviceの10%割引を受けるには、 こちらをクリックしてください 。. American Journal Expertsの10%割引を受けるには、 こちらをクリックしてください 。

英文校正サービスの利用は、このジャーナルに掲載されるための条件ではないこと、また論文審査や受理を保証するものではないことに留意してください。 영어 원고의 경우, 에디터 및 리뷰어들이 귀하의 원고에 실린 결과물을 정확하게 평가할 수 있도록, 그들이 충분히 이해할 수 있을 만한 수준으로 작성되어야 합니다. 만약 영작문과 관련하여 도움을 받기를 원하신다면 다음의 사항들을 고려하여 주십시오:

  • 영어 튜토리얼 페이지 에 방문하여 영어로 글을 쓸 때 자주하는 실수들을 확인합니다.
  • 귀하의 원고의 표현을 명확히 해줄 영어 원어민 동료를 찾아서 리뷰를 의뢰합니다
  • 리뷰에 대비하여, 원고의 의미를 명확하게 해주고 리뷰에서 요구하는 문제점들을 식별해서 영문 수준을 향상시켜주는 전문 영문 교정 서비스를 이용합니다. Nature Research Editing Service 와 American Journal Experts 에서 저희와 협약을 통해 서비스를 제공하고 있습니다. SpringerOpen에서는 위의 두 가지의 서비스를 첫 논문 투고를 위해 사용하시는 경우, 10%의 할인을 제공하고 있습니다. Nature Research Editing Service이용시 10% 할인을 요청하기 위해서는 여기 를 클릭해 주시고, American Journal Experts 이용시 10% 할인을 요청하기 위해서는 여기 를 클릭해 주십시오.

영문 교정 서비스는 게재를 위한 요구사항은 아니며, 해당 서비스의 이용이 피어 리뷰에 논문이 선택되거나 게재가 수락되는 것을 의미하거나 보장하지 않습니다.

Data and materials

For all journals, SpringerOpen strongly encourages all datasets on which the conclusions of the manuscript rely to be either deposited in publicly available repositories (where available and appropriate) or presented in the main paper or additional supporting files, in machine-readable format (such as spread sheets rather than PDFs) whenever possible. Please see the list of recommended repositories in our editorial policies.

For some journals, deposition of the data on which the conclusions of the manuscript rely is an absolute requirement. Please check the Instructions for Authors for the relevant journal and article type for journal specific policies.

For all manuscripts, information about data availability should be detailed in an ‘Availability of data and materials’ section. For more information on the content of this section, please see the Declarations section of the relevant journal’s Instruction for Authors. For more information on SpringerOpen's policies on data availability, please see our editorial policies .

Formatting the 'Availability of data and materials' section of your manuscript

The following format for the 'Availability of data and materials section of your manuscript should be used:

"The dataset(s) supporting the conclusions of this article is(are) available in the [repository name] repository, [unique persistent identifier and hyperlink to dataset(s) in http:// format]."

The following format is required when data are included as additional files:

"The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s))."

For databases, this section should state the web/ftp address at which the database is available and any restrictions to its use by non-academics.

For software, this section should include:

  • Project name: e.g. My bioinformatics project
  • Project home page: e.g. http://sourceforge.net/projects/mged
  • Archived version: DOI or unique identifier of archived software or code in repository (e.g. enodo)
  • Operating system(s): e.g. Platform independent
  • Programming language: e.g. Java
  • Other requirements: e.g. Java 1.3.1 or higher, Tomcat 4.0 or higher
  • License: e.g. GNU GPL, FreeBSD etc.
  • Any restrictions to use by non-academics: e.g. licence needed

Information on available repositories for other types of scientific data, including clinical data, can be found in our editorial policies .

What should be cited?

Only articles, clinical trial registration records and abstracts that have been published or are in press, or are available through public e-print/preprint servers, may be cited.

Unpublished abstracts, unpublished data and personal communications should not be included in the reference list, but may be included in the text and referred to as "unpublished observations" or "personal communications" giving the names of the involved researchers. Obtaining permission to quote personal communications and unpublished data from the cited colleagues is the responsibility of the author. Either footnotes or endnotes are permitted. Journal abbreviations follow Index Medicus/MEDLINE.

Any in press articles cited within the references and necessary for the reviewers' assessment of the manuscript should be made available if requested by the editorial office.

Preparing figures

When preparing figures, please follow the formatting instructions below.

  • Figure titles (max 15 words) and legends (max 300 words) should be provided in the main manuscript, not in the graphic file.
  • Tables should NOT be submitted as figures but should be included in the main manuscript file.
  • Multi-panel figures (those with parts a, b, c, d etc.) should be submitted as a single composite file that contains all parts of the figure.
  • Figures should be numbered in the order they are first mentioned in the text, and uploaded in this order.
  • Figures should be uploaded in the correct orientation.
  • Figure keys should be incorporated into the graphic, not into the legend of the figure.
  • Each figure should be closely cropped to minimize the amount of white space surrounding the illustration. Cropping figures improves accuracy when placing the figure in combination with other elements when the accepted manuscript is prepared for publication on our site. For more information on individual figure file formats, see our detailed instructions.
  • Individual figure files should not exceed 10 MB. If a suitable format is chosen, this file size is adequate for extremely high quality figures.
  • Please note that it is the responsibility of the author(s) to obtain permission from the copyright holder to reproduce figures (or tables) that have previously been published elsewhere. In order for all figures to be open access, authors must have permission from the rights holder if they wish to include images that have been published elsewhere in non open access journals. Permission should be indicated in the figure legend, and the original source included in the reference list.

Figure file types

We accept the following file formats for figures:

  • EPS (suitable for diagrams and/or images)
  • PDF (suitable for diagrams and/or images)
  • Microsoft Word (suitable for diagrams and/or images, figures must be a single page)
  • PowerPoint (suitable for diagrams and/or images, figures must be a single page)
  • TIFF (suitable for images)
  • JPEG (suitable for photographic images, less suitable for graphical images)
  • PNG (suitable for images)
  • BMP (suitable for images)
  • CDX (ChemDraw - suitable for molecular structures)

Figure size and resolution

Figures are resized during publication of the final full text and PDF versions to conform to the SpringerOpen standard dimensions, which are detailed below.

Figures on the web:

  • width of 600 pixels (standard), 1200 pixels (high resolution).

Figures in the final PDF version:

  • width of 85 mm for half page width figure
  • width of 170 mm for full page width figure
  • maximum height of 225 mm for figure and legend
  • image resolution of approximately 300 dpi (dots per inch) at the final size

Figures should be designed such that all information, including text, is legible at these dimensions. All lines should be wider than 0.25 pt when constrained to standard figure widths. All fonts must be embedded.

Figure file compression

Vector figures should if possible be submitted as PDF files, which are usually more compact than EPS files.

  • TIFF files should be saved with LZW compression, which is lossless (decreases file size without decreasing quality) in order to minimize upload time.
  • JPEG files should be saved at maximum quality.
  • Conversion of images between file types (especially lossy formats such as JPEG) should be kept to a minimum to avoid degradation of quality.

If you have any questions or are experiencing a problem with figures, please contact the customer service team at [email protected] .

Preparing tables

When preparing tables, please follow the formatting instructions below.

  • Tables should be numbered and cited in the text in sequence using Arabic numerals (i.e. Table 1, Table 2 etc.).
  • Tables less than one A4 or Letter page in length can be placed in the appropriate location within the manuscript.
  • Tables larger than one A4 or Letter page in length can be placed at the end of the document text file. Please cite and indicate where the table should appear at the relevant location in the text file so that the table can be added in the correct place during production.
  • Larger datasets, or tables too wide for A4 or Letter landscape page can be uploaded as additional files. Please see [below] for more information.
  • Tabular data provided as additional files can be uploaded as an Excel spreadsheet (.xls ) or comma separated values (.csv). Please use the standard file extensions.
  • Table titles (max 15 words) should be included above the table, and legends (max 300 words) should be included underneath the table.
  • Tables should not be embedded as figures or spreadsheet files, but should be formatted using ‘Table object’ function in your word processing program.
  • Color and shading may not be used. Parts of the table can be highlighted using superscript, numbering, lettering, symbols or bold text, the meaning of which should be explained in a table legend.
  • Commas should not be used to indicate numerical values.

If you have any questions or are experiencing a problem with tables, please contact the customer service team at [email protected] .

Preparing additional files

As the length and quantity of data is not restricted for many article types, authors can provide datasets, tables, movies, or other information as additional files.

All Additional files will be published along with the accepted article. Do not include files such as patient consent forms, certificates of language editing, or revised versions of the main manuscript document with tracked changes. Such files, if requested, should be sent by email to the journal’s editorial email address, quoting the manuscript reference number.

Results that would otherwise be indicated as "data not shown" should be included as additional files. Since many web links and URLs rapidly become broken, SpringerOpen requires that supporting data are included as additional files, or deposited in a recognized repository. Please do not link to data on a personal/departmental website. Do not include any individual participant details. The maximum file size for additional files is 20 MB each, and files will be virus-scanned on submission. Each additional file should be cited in sequence within the main body of text.

Submit manuscript

  • Editorial Board
  • Sign up for article alerts and news from this journal
  • Follow us on Twitter
  • Follow us on Facebook

Affiliated with

Neuer Inhalt

The Ultrasound Journal is affiliated with the World Interactive Network Focused on Critical UltraSound (WINFOCUS)

Annual Journal Metrics

2022 Citation Impact 3.4 - 2-year Impact Factor 3.4 - 5-year Impact Factor 1.534 - SNIP (Source Normalized Impact per Paper) 0.724 - SJR (SCImago Journal Rank)

2023 Speed 22 days submission to first editorial decision for all manuscripts (Median) 116 days submission to accept (Median)

2023 Usage  645,614 downloads 1,610 Altmetric mentions 

  • More about our metrics
  • ISSN: 2524-8987 (electronic)

Warning: The NCBI web site requires JavaScript to function. more...

U.S. flag

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Cover of Identification of breech presentation

  • Identification of breech presentation

Evidence review L

NICE Guideline, No. 201

National Guideline Alliance (UK) .

  • Copyright and Permissions

Review question

What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation?

Introduction

Breech presentation in late pregnancy may result in prolonged or obstructed labour for the woman. There are interventions that can correct or assist breech presentation which are important for the woman’s and the baby’s health. This review aims to determine the most effective way of identifying a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Table 1. Summary of the protocol (PICO table).

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

One single centre randomised controlled trial (RCT) was included in this review ( McKenna 2003 ). The study was carried out in Northern Ireland, UK. The study compared ultrasound examination at 30-32 and 36-37 weeks with maternal abdomen palpation during the same gestation period. The intervention group in the study had the ultrasound scans in addition to the abdomen palpation, while the control group had only the abdomen palpation. Clinical management options reported in the study based on the ultrasound scan or the abdomen palpation include referral for full biophysical assessment which included umbilical artery Doppler ultrasound, early antenatal review, admission to antenatal ward, and induction of labour.

The included study is summarised in Table 2 .

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2 .

Table 2. Summary of included studies.

Summary of included studies.

See the full evidence tables in appendix D . No meta-analysis was conducted (and so there are no forest plots in appendix E ).

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

One study, a cost utility analysis was included ( Wastlund 2019 ).

See the literature search strategy in appendix B and economic study selection flow chart in appendix G .

Studies not included in this review with reasons for their exclusions are provided in appendix K .

Summary of studies included in the economic evidence review

For full details of the economic evidence, see the economic evidence tables in appendix H and economic evidence profiles in appendix I .

Wastlund (2019) assessed the cost effectiveness of universal ultrasound scanning for breech presentation at 36 weeks’ gestational age in nulliparous woman (N=3879). The comparator was selective ultrasound scanning which was reported as current practice. In this instance, fetal presentation was assessed by palpation of the abdomen by a midwife, obstetrician or general practitioner. The sensitivity of this method ranges between 57%-70% whereas ultrasound scanning is detected with 100% sensitivity and 100% specificity. Women in the selective ultrasound scan arm only received an ultrasound scan after detection of a breech presentation by abdominal palpation. Where a breech was detected, a woman was offered external cephalic version (ECV). The structure of the model undertook a decision tree, with end states being the mode of birth; either vaginal, elective or emergency caesarean section. Long term health outcomes were modelled based on the mortality risk associated with each mode of birth. Average lifetime quality-adjusted life years (QALYs) were estimated from Euroqol general UK population values.

Only the probabilistic results (n=100000 simulations) were reported which showed that on average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39% compared with selective ultrasound scanning. The expected cost per person with breech presentation of universal ultrasound was £2957 (95% Credibility Interval [CrI]: £2922 to £2991), compared to £2,949 (95%CrI: £2915 to £2984) from selective ultrasound. The expected QALYs per person was 24.27615 in the universal ultrasound cohort and 24.27582 in the selective ultrasound cohort. The incremental cost effectiveness ratio (ICER) from the probabilistic analysis was £23611 (95%CrI: £8184 to £44851).

A series of one-way sensitivity analysis were conducted which showed that the most important cost parameter was the unit cost of a universal ultrasound scan. This parameter is particularly noteworthy as the study costed this scan at a much lower value than the ‘standard antenatal ultrasound’ scan in NHS reference costs on the basis that such a scan can be performed by a midwife during a routine antenatal care visit in primary care. According to the NICE guideline manual economic evaluation checklist this model was assessed as being directly applicable with potentially severe limitations. The limitations were mostly attributable to the limitations of the clinical inputs.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements, comparison 1. routine ultrasound scan versus selective ultrasound scan, critical outcomes, unexpected breech presentation in labour.

No evidence was identified to inform this outcome.

Mode of birth

  • Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of women who had elective caesarean section: RR 1.22 (95% CI 0.91 to 1.63).
  • Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had emergency caesarean section: RR 1.20 (95% CI 0.90 to 1.60).
  • High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had vaginal birth: RR 0.95 (95% CI 0.89 to 1.01).

Important outcomes

Maternal anxiety, women’s experience and satisfaction of care, gestational age at birth.

  • High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies’ born between 39-42 gestational weeks: RR 0.98 (95% CI 0.94 to 1.02).

Admission to neonatal unit

  • Low quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies admitted into the neonatal unit: RR 0.83 (95% CI 0.51 to 1.35).

Economic evidence statements

One directly applicable cost-utility analysis from the UK with potentially serious limitations compared universal ultrasound scanning for breech presentation at 36 weeks’ gestational age with selective ultrasound scanning, stated as current practice. Universal ultrasound scanning was found to be borderline cost effective; the incremental cost-effectiveness ratio was £23611 per QALY gained. The cost of the scan was seen to be a key driver in the cost effectiveness result.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

Unexpected breech presentation in labour and mode of birth were prioritised as critical outcomes by the committee. This reflects the different options available to women with a known breech presentation in pregnancy and the different choices that women make. There are some women and/or clinicians who may feel uncomfortable with the risks of aiming for vaginal breech birth, and for these women and/or clinicians avoiding an unexpected breech presentation in labour would be the preferred option.

As existing evidence suggests that aiming for vaginal breech birth carries greater risk to the fetus than planned caesarean birth, it is important to consider whether earlier detection of the breech presentation would reduce the risk of these outcomes.

The committee agreed that maternal anxiety and women’s experience and satisfaction of care were important outcomes to consider as the introduction of an additional routine scan during pregnancy could have a treatment burden for women. Gestational age at birth and admission to neonatal unit were also chosen as important outcomes as the committee wanted to find out whether earlier detection of breech presentation would have an impact on whether the baby was born preterm, and as a consequence admitted to the neonatal unit. These outcomes were agreed to be important rather than critical as they are indirect outcomes of earlier detection of breech presentation.

The quality of the evidence

The quality of the evidence ranged from low to high. Most of the evidence was rated high or moderate, with only 1 outcome rated as low. The quality of the evidence was downgraded due to imprecision around the effect estimates for emergency caesarean section, elective caesarean section and admissions to neonatal unit.

No evidence was identified for the following outcomes: unexpected breech presentation in labour, maternal anxiety, women’s experiences and satisfaction of care.

The committee had hoped to find evidence that would inform whether early identification of breech presentation had an impact on preterm births, and although the review reported evidence for gestational age as birth, the available evidence was for births 39-42 weeks of gestation.

Benefits and harms

The available evidence compared routine ultrasound scanning with selective ultrasound scanning, and found no clinically important differences for mode of birth, gestational age at birth, or admissions to the neonatal unit. However, the committee discussed that it was important to note that the study did not focus on identifying breech presentation. The committee discussed the differences between the intervention in the study, which was an ultrasound scan to assess placental maturity, liquor volume, and fetal weight, to an ultrasound scan used to detect breech presentation. Whilst the ultrasound scan in the study has the ability to determine breech presentation, there are additional and costlier training required for the assessment of the other criteria. As such, it is important to separate the interventions. The committee also highlighted that the study did not look at whether an identification of breech presentation had an impact on the outcomes which were selected for this review.

In light of this, the committee felt that they were unable to reach a conclusion as to whether routine scanning to identify breech presentation, was associated with any benefits or harms. The committee agreed that while this review suggests routine ultrasound scanning to be no more effective than selective scanning, it does not definitively establish equivalence. Therefore, the committee agreed to recommend a continuation of the current practice with selective scanning and make a research recommendation to compare the clinical and cost effectiveness of routine ultrasound scanning versus selective ultrasound scanning from 36 weeks to identify fetal breech presentation.

Cost effectiveness and resource use

The committee acknowledged that there was included economic evidence on the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

The 1 included study suggested that offering a routine scan for breech is borderline cost effective. A key driver of cost effectiveness was the cost of the scan, which was substantially lower in the economic model than the figure quoted in NHS reference costs for routine ultrasound scanning. The committee noted that a scan for breech presentation only is a simpler technique and uses a cheaper machine. The committee agreed that the other costing assumptions presented in the study seemed appropriate.

However, the committee expressed concerns about the cohort study which underpinned the economic analysis which had a high risk of bias. The committee noted that a number of assumptions in the model which were key drivers of cost effectiveness, including the palpation diagnosis rates and prevalence of breech position, were from this 1 cohort study. This increased the uncertainty around the cost effectiveness of the routine scan. The committee also noted that, whilst the cost of the scan was fairly inexpensive, the resource impact would be substantial if a routine scan for breech presentation was offered to all pregnant women.

Overall, the committee felt that the clinical and cost effectiveness evidence presented was not strong enough to recommend offering a routine ultrasound scan given the potential for a significant resource impact. The recommendation to offer abdominal palpation to all pregnant women, and to offer an ultrasound scan where breech is suspected reflects current practice and so no substantial resource impact is anticipated.

McKenna 2003

Wastlund 2019

Appendix A. Review protocols

Review protocol for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 244K)

Appendix B. Literature search strategies

Literature search strategies for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 370K)

Appendix C. Clinical evidence study selection

Clinical study selection for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 117K)

Appendix D. Clinical evidence tables

Clinical evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 213K)

Appendix E. Forest plots

Forest plots for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

This section includes forest plots only for outcomes that are meta-analysed. Outcomes from single studies are not presented here, but the quality assessment for these outcomes is provided in the GRADE profiles in appendix F .

Appendix F. GRADE tables

GRADE tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 196K)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

A single economic search was undertaken for all topics included in the scope of this guideline. One economic study was identified which was applicable to this review question. See supplementary material 2 for details.

Appendix H. Economic evidence tables

Economic evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 143K)

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 129K)

Appendix J. Economic analysis

Economic evidence analysis for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation, clinical studies, table 8 excluded studies and reasons for their exclusion.

View in own window

StudyReason for exclusion
Abuhamad, A., Zhao, Y., Abuhamad, S., Sinkovskaya, E., Rao, R., Kanaan, C., Platt, L., Standardized Six-Step Approach to the Performance of the Focused Basic Obstetric Ultrasound Examination, American Journal of Perinatology, 33, 90–8, 2016 [ ] Prospective cohort study - no relevant comparison
Balogun, O. A. A., Pedroza, C., Sibai, B. M., Blackwell, S. C., Chauhan, S. P., Serial third trimester ultrasound vs. routine care in uncomplicated pregnancies: a randomized controlled trial (UP trial), American Journal of Obstetrics and Gynecology, 218, S92, 2018 Conference abstract
BelangerK, HobbinsJC, MullerJP, HowardS, Neurological testing in ultrasound exposed infants, American Journal of Obstetrics and Gynecology, 174, 413, 1996 Conference abstract
Bricker, L., Medley, N., Pratt, J. J., Routine ultrasound in late pregnancy (after 24 weeks’ gestation), Cochrane Database of Systematic Reviews, 2015 [ ] [ ] Systematic review. references checked, 2 additional studies included ( ; Wladimiroff 1980)
Carbillon, L., Benbara, A., Tigaizin, A., Murtada, R., Fermaut, M., Belmaghni, F., Bricou, A., Boujenah, J., Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies, BMC Pregnancy and Childbirth, 20, 263, 2020 [ ] [ ] Study design does not meet inclusion criteria. Debate article.
Ciobanu, A., Formuso, C., Syngelaki, A., Akolekar, R., Nicolaides, K. H., Prediction of small-for-gestational-age neonates at 35-37 weeks’ gestation: contribution of maternal factors and growth velocity between 20 and 36 weeks, Ultrasound in obstetrics & gynecology, 53, 488–495, 2019 [ ] Prediction model study - no relevant comparison
Lalor,J., Russell,N., McParland,P., Routine screening and detection of fetal anomalies in a predominantly midwifery-led ultrasound service, Evidence Based Midwifery, 6, 87–94, 2008 No relevant comparison
Lindqvist, P. G., Pettersson, K., Moren, A., Kublickas, M., Nordstrom, L., Routine ultrasound examination at 41 weeks of gestation and risk of post-term severe adverse fetal outcome: A retrospective evaluation of two units, within the same hospital, with different guidelines, BJOG: An International Journal of Obstetrics and Gynaecology, 121, 1108–1115, 2014 [ ] No relevant intervention and comparison and study design does not meet inclusion criteria. A retrospective Cohort study
NeilsonJP, MunjanjaSP, WhitfieldCR, Screening for small for dates fetuses: a controlled trial, BMJ, 289, 1179–82, 1984 [ ] [ ] No relevant comparison
NewnhamJP, EvansSF, MichaelCA, et al., Effects of frequent ultrasound during pregnancy: a randomised controlled trial, Lancet, 342, 887–91, 1993 [ ] No relevant comparison
Odibo, A. O., Routine ultrasound examination at 41 weeks of gestation does not improve perinatal outcomes, BJOG: An International Journal of Obstetrics and Gynaecology, 121, 1116, 2014 Commentary on Lindqvist 2014 (an included study).
Oniya, O., Ledingham, M., Duncan, A., Ultrasound surveillance in the high risk patient-does it deliver?, BJOG: An International Journal of Obstetrics and Gynaecology, 120, 135, 2013 Conference abstract
Ray, C. L., Morin, L., Routine Versus Indicated Third Trimester Ultrasound: Is a Randomized Trial Feasible?, Journal of Obstetrics and Gynaecology Canada, 31, 113–119, 2009 [ ] Mixed methods study examining viability of conducting RCT of routine vs indicated ultrasound scan - no relevant data
Revankar, K. G., Dhumale, H., Pujar, Y., A randomized controlled study to assess the role of routine third trimester ultrasound in low-risk pregnancy on antenatal interventions and perinatal outcome, Journal of SAFOG, 6, 139–143, 2014 Study not conducted in Work Bank high-income country
Skrastad,R.B., Eik-Nes,S.H., Sviggum,O., Johansen,O.J., Salvesen,K.A., Romundstad,P.R., Blaas,H.G., A randomized controlled trial of third-trimester routine ultrasound in a non-selected population, Acta Obstetricia et Gynecologica Scandinavica, 92, 1353–1360, 2013 [ ] No relevant comparison - RCT comparing routine ultrasound at 33 weeks to clinically-indicated ultrasound only, to detect SGA or LGA babies
Triunfo, S., Crovetto, F., Scazzocchio, E., Parra-Saavedra, M., Gratacos, E., Figueras, F., Contingent versus routine third-trimester screening for late fetal growth restriction, Ultrasound in obstetrics & gynecology, 47, 81–8, 2016 [ ] Prediction model study - no relevant data
Wastlund, D., Moraitis, A. A., Dacey, A., Sovio, U., Wilson, E. C. F., Smith, G. C. S., Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis, PLoS Medicine / Public Library of SciencePLoS Med, 16, e1002778, 2019 [ ] [ ] Conference abstract
Wastlund, D., Moraitis, A., Dacey, A., Sovio, U., Wilson, E., Smith, G., Screening for breech presentation using late pregnancy ultrasonography: A prospective cohort study and cost-effectiveness analysis, BJOG: An International Journal of Obstetrics and Gynaecology, 126, 125, 2019 [ ] [ ] Prospective cohort study examining routine vs indicated scan - data reported according to type of presentation rather than type of intervention received.
WladimiroffJW, LaarJ, Ultrasonic measurement of fetal body size. A randomized controlled trial, Acta Obstetricia et Gynecologica Scandinavica, 59, 177–9, 1980 [ ] No relevant intervention or comparison. Routine ultrasound between 32 and 36 weeks compared to selective ultrasound based on abdominal palpation.

Economic studies

A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.

Appendix L. Research recommendations

Research recommendations for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 164K)

Evidence reviews underpinning recommendations 1.2.36 to 1.2.37

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

  • Cite this Page National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
  • PDF version of this title (518K)

In this Page

Other titles in this collection.

  • NICE Evidence Reviews Collection

Related NICE guidance and evidence

  • NICE Guideline 201: Antenatal care

Supplemental NICE documents

  • Supplement 1: Methods (PDF)
  • Supplement 2: Health economics (PDF)

Related information

  • PMC PubMed Central citations
  • PubMed Links to PubMed

Similar articles in PubMed

  • Review Management of breech presentation: Antenatal care: Evidence review M [ 2021] Review Management of breech presentation: Antenatal care: Evidence review M National Guideline Alliance (UK). 2021 Aug
  • Vaginal delivery of breech presentation. [J Obstet Gynaecol Can. 2009] Vaginal delivery of breech presentation. Kotaska A, Menticoglou S, Gagnon R, MATERNAL FETAL MEDICINE COMMITTEE. J Obstet Gynaecol Can. 2009 Jun; 31(6):557-566.
  • [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. [Akush Ginekol (Sofiia). 1996] [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. Dimitrov A, Borisov S, Nalbanski B, Kovacheva M, Chintolova G, Dzherov L. Akush Ginekol (Sofiia). 1996; 35(1-2):7-9.
  • Review Cephalic version by moxibustion for breech presentation. [Cochrane Database Syst Rev. 2005] Review Cephalic version by moxibustion for breech presentation. Coyle ME, Smith CA, Peat B. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD003928. Epub 2005 Apr 18.
  • Review Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). [Cochrane Database Syst Rev. 2005] Review Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Hofmeyr GJ, Kulier R. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD001063. Epub 2005 Apr 18.

Recent Activity

  • Identification of breech presentation Identification of breech presentation

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

statistics

Official websites use .gov

Secure .gov websites use HTTPS

presentation in ultrasound report

  • 2024 Trafficking in Persons Report

A PDF accessible version will be posted as soon as the ongoing accessibility and accommodation updates are concluded. Your patience is appreciated.

If you have questions about the 2024 Trafficking in Persons Report, please email  [email protected] .

  • Message From the Secretary of State

Dear Reader:

Human trafficking is a stain on the conscience of our society.  It fuels crime, corruption, and violence.  It distorts our economies and harms our workers. And it violates the fundamental right of all people to be free.

Around the globe, an estimated 27 million people are exploited for labor, services, and commercial sex.  Through force, fraud, and coercion, they are made to toil in fields and factories, in restaurants and residences.  Traffickers prey on some of the world’s most marginalized and vulnerable individuals – profiting from their plight.

The State Department’s annual Trafficking in Persons Report provides the world’s most comprehensive assessment of this abhorrent practice, as well as efforts by governments and stakeholders around the globe to combat it.  By measuring progress in 188 countries – including the United States – we are advancing President Biden’s commitment to prevent trafficking, prosecute perpetrators, and protect survivors.

Even as this resource covers long-standing forms and methods of trafficking, it also examines the growing role of technology in both facilitating exploitation and countering it.

Digital tools have amplified the reach, scale, and speed of trafficking. Perpetrators use dating apps and online ads to recruit victims.  They use online platforms to sell illicit sexual content.  They leverage encrypted messaging and digital currencies to evade detection.

At the same time, technology is also one of our most powerful tools to combat this enduring scourge.  Mobile phones, social media platforms, and artificial intelligence make it possible for advocates and law enforcement to raise greater awareness about the rights of workers and migrants, locate victims and perpetrators of online sexual exploitation, and analyze large amounts of data to detect emerging human trafficking trends.

As technology makes it easier for traffickers to operate across geographies and jurisdictions, those of us committed to rooting out this horrendous crime – in government, businesses, civil society – can and must work together and coordinate our efforts.

I am grateful to everyone who contributed to this report, especially the State Department’s Human Trafficking Expert Consultant Network, who helps ensure our findings and recommendations are informed by those with lived experience of human trafficking.

I also want to recognize our TIP Report Heroes who have been essential partners in this work.  For the past 20 years, the Department of State has honored more than 170 such champions of human dignity and decency from over 90 countries – survivors, government leaders, law enforcement officials, lawyers, social workers.  Many of them have put their own safety at risk to support victims and share their stories.

The courage and persistence of survivors and advocates like these humble and inspire us all as we continue working to build a safer and more just world.

Antony Blinken

  • Message From the Ambassador-at-Large

Innovation drives successful anti-trafficking work.  As criminals continually adapt to take advantage of new vulnerabilities and opportunities to exploit others, we must persistently keep pace with a rapidly evolving trafficking landscape.  This year’s introduction examines the role of digital technology, which has had a profound impact on trafficking methods and trends in recent years.  Traffickers use online platforms to recruit, groom, defraud, coerce, and exploit victims, taking advantage of the potential for anonymity offered by online spaces.  At the same time, when harnessed effectively, digital technology can strengthen our anti-trafficking response, providing opportunities for stakeholders to strengthen prevention efforts, protect victims, and partner with survivors and other stakeholders to combat the crime.

In our fight against human trafficking, we must constantly strive to connect and unite through innovation, including optimization of our use of digital technology.  Traffickers take advantage of the ever-shifting nature of the internet to exploit others; it is imperative that we too embrace technology to counter this trend.   Digital technology has given us new ways to prevent trafficking, protect victims, prosecute bad actors, and forge global partnerships to combat this crime.  This year’s report highlights a range of successful and promising innovations that set us on that path.  Developing partnerships and empowering communities most affected by human trafficking are key to combating this crime.  This report examines, for example, how current efforts to prevent and address forced labor are buoyed by strategic partnerships with workers, including worker-led approaches to advancing labor rights and standards.

The internet can provide spaces to share information, for example to train and educate youth regarding online safety, empower workers to know and protect their rights, and educate vulnerable populations to recognize indicators of exploitation.  Digital tools can provide human trafficking victims with streamlined access to services such as hotlines, peer support and therapy, and other resources for technical training and financial literacy to help survivors navigate the exit and recovery stages of human trafficking.  Technological advances can increase the speed and accuracy of data collection, an area that when harnessed effectively can aid in the identification of trafficking patterns and trends.  Stakeholders can use technology to strengthen communication and information-sharing tools that incorporate workers’ voices, increase transparency and accountability in supply chains, and streamline collaboration and data-sharing among stakeholders.

This year’s introduction also covers a topic of personal importance to me as a former prosecutor.   Utilizing strategic investigative processes can effectively shift the burden of proof away from a reliance on victim testimony, which can endanger and retraumatize victims, and onto the prosecuting authority to both strengthen criminal justice procedures and better facilitate the safety and long-term well-being of victims and survivors.  Strengthening partnerships with survivors and innovating for greater inclusion of historically marginalized communities such as those with disabilities, are crucial to the anti-trafficking movement.  Survivors must continue to be consulted early and often in the development and implementation of anti-trafficking work.  Their firsthand knowledge of the ways in which traffickers are utilizing technology for exploitation is critical to ensure effective prevention, protection, and prosecution efforts.

Governments have a responsibility to guide and leverage efforts, including the use of digital technology, to protect the rights and safety of their citizens; however, governments cannot do this alone.  Collaboration and partnerships among stakeholders – governments, tech companies, NGOs, survivor communities, and financial institutions – are more important than ever to creating a safer world without human trafficking.  A fierce commitment to innovation has the power to renew and strengthen the deep connections that bind together all of us working to end human trafficking.  The United States is proud to work alongside our partners at home and overseas as we document and disseminate efforts to end this terrible crime while also recognizing the heroes whose work around the globe brings hope to victims, empowerment to marginalized communities, and motivation to continue our collective efforts.

  • Human Trafficking Defined

The Trafficking Victims Protection Act of 2000, as amended (TVPA), defines “severe forms of trafficking in persons” as:

  • sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or
  • the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

A victim need not be physically transported from one location to another for the crime to fall within this definition.

Exploring the Role and Impacts of Digital Technology on Human Trafficking

In today’s rapidly evolving world, technology is often a double-edged sword.   While technology has provided innovative solutions to preventing and addressing human trafficking, it has also prompted complex ethical questions and created new opportunities for criminals, including human traffickers, to be increasingly sophisticated in exploiting individuals for profit.   Traffickers use technology to recruit, control, market and exploit vulnerable individuals while also evading detection.   Traffickers do this, for example, by using the Internet to advertise and sell children online for sex, advertise false jobs on social media platforms that are actually human trafficking schemes, transfer cryptocurrency to other traffickers, and perpetuate online scam operations.   At the same time, anti-trafficking stakeholders are using technological innovations to prevent human trafficking, protect victims, and prosecute traffickers.   The 2024 Trafficking in Persons Report (TIP Report) introduction explores the challenges associated with digital technology in the fight against human trafficking and highlights how it can be used effectively by the anti-trafficking community.

Defining “Digital Technology”

Digital technology refers to an ever-expanding set of electronic systems and resources that facilitate learning, communication, entertainment, and more.   Examples include hardware, such as computers, smartphones and mobile devices, and robotics; software, including mobile applications, geolocation, online games, financial databases, web-based and cloud-based systems, and artificial intelligence (AI); and other online services, such as websites, video streaming, blogs, and social media.   For the purposes of this report, digital technologies are explored through their use by traffickers as well as by key anti-trafficking stakeholders and beneficiaries.

The Intersection between Digital Technology and Human Trafficking

One way digital technology and human trafficking can intersect occurs when traffickers use online platforms to exploit victims.   While not a novel phenomenon, renewed attention was brought to the issue because many people shifted their daily activities online at the height of the COVID-19 pandemic.   Reports from several countries demonstrated drastic increases in online commercial sexual exploitation and sex trafficking, including online sexual exploitation of children (OSEC), and demand for and distribution of child sexual abuse material (CSAM).   Traffickers have continued to advance schemes to exploit individuals using digital tools to groom, deceive, control, and exploit victims.   Some of these schemes lure individuals hundreds of miles away, including across borders, while others do not require them to leave their homes.  Increasingly, victims and survivors of human trafficking have shared that they first connected with their traffickers online.   While traffickers continue to refine and advance their use of digital technologies, governments and other anti-trafficking stakeholders must do the same to combat human trafficking.

How Traffickers Use Technology to Facilitate Trafficking

Human traffickers use a wide range of tactics to manipulate and exploit victims—using technology at every stage of their criminal activities, from the initial planning and execution of the scheme to the way in which they coerce, monitor, and maintain individuals to further their exploitative purpose and increase their profits.

Traffickers use the Internet to facilitate the identification and grooming of potential victims.   Traffickers often target and victimize individuals in vulnerable situations such as those experiencing conflict, natural disasters, poverty, challenging home lives, systemic oppression, or a combination of hardships.   The UN Office on Drugs and Crime (UNODC) identified “hunting” and “fishing” as two common strategies perpetrators use to deceive and recruit victims.   According to UNODC, online platforms help traffickers search proactively and anonymously for a specific type of individual who they believe is particularly susceptible to further their scheme (the hunting process), or passively attract potential victims by posting online and waiting for a response (the fishing process).   Perpetrators may use social media, online advertisements, websites, dating apps, and gaming platforms – or fraudulent or deceptive duplications of such tools – to hide their true identity through fake accounts and profiles while interacting with potential victims.   Once potential victims are identified and contact is established, communication through the Internet serves as a powerful tool to deceive individuals with false promises of education, employment, housing, or romantic relationships only to lure them into labor and sex trafficking situations.   For example, a trafficker may create an online business website, perhaps posing as a talent recruiter, on which they often include realistic photos to gain a victim’s trust and make them believe the opportunity is authentic and will help advance their career or improve their life.   In these cases, traffickers trick the victim into believing they can legitimately earn income not only for themselves, but for their families as well.   As trust is established, the trafficker manipulates and traps the individual in an exploitative situation through force, fraud, or coercion.   Tactics such as threatening physical abuse or harm to an individual, their reputation, future employment, financial prospects, or their loved ones, are used by traffickers to foster fear.   The internet can also serve as a platform to escalate the exploitative scheme further, including via sextortion.

The Federal Bureau of Investigation (FBI) defines sextortion as a serious crime that occurs when a perpetrator threatens to distribute private and sensitive material if the victim does not provide images of a sexual nature, sexual favors, or money.   The perpetrator, who often poses as a love interest, entices individuals to send sensitive images, which the victim believes are being shared privately, but the perpetrator then uses the images to control and coerce their victims to produce more images, perform sexual favors, or give money in cases involving sex trafficking or forced labor.   In addition to blackmailing the victims for large sums of money, traffickers may also use the content to generate additional revenue by selling the sensitive material on illicit platforms.

Additionally, traffickers can use the Internet to facilitate forced criminality, an increasingly common mechanism involving traffickers coercing their victims to engage in or support criminal activities ranging from working as part of online scam operations to commercial sex.   In online scam operations, traffickers largely recruit victims through deceitful job listings online, confine them in gated compounds, and force them to engage in online criminal activity under threat of serious harm.   Online scam operations include illegal online gambling, cryptocurrency investment schemes, and romance scams, all of which involve the victim of trafficking forming relationships with individuals in order to defraud them of significant sums.   Some traffickers compel victims to continue to work by threatening that if they seek help, they will be prosecuted for the unlawful acts committed as a direct result of being trafficked; while others are simply unaware that they are trafficking victims.

In sum, traffickers use digital tools like the Internet to amplify the reach, scale, and speed of their trafficking operations.   While the methods and means may have evolved with technological developments, the exploitation at the heart of trafficking persists, underscoring the urgent need for comprehensive and innovative approaches to investigate and combat this crime.

Challenges and Risks Technology Presents for the Anti-trafficking Community

Digital technology has broadened the scope and scale of operations for traffickers as it allows the flexibility to target and exploit victims across the world while remaining hidden and more difficult to trace.   Traffickers adapt their schemes to take advantage of the obscurity available with new online tools, such as hiding behind anonymization tools or software, and benefiting from loose regulations of online platforms.   These challenges make it increasingly difficult for law enforcement and anti-trafficking stakeholders to identify and implement coordinated solutions fast enough to effectively combat technology-facilitated human trafficking.  Constant evolution in digital technology and the ways in which it is being used also makes it difficult to concentrate efforts or decipher trafficking indicators on a given platform, because law enforcement agencies must continuously adapt their tactics, develop technical expertise, and collaborate with technology companies to effectively combat trafficking.   Additionally, NGOs and service providers with data relevant to the field may struggle with how to effectively share information while considering data ownership and ensuring privacy is being maintained and protected.

Cross-Sector Coordination Challenges  

Traffickers have widened their reach by communicating with and recruiting victims globally, which has created a need for greater global coordination among anti-trafficking stakeholders and technology experts.   These stakeholders face several challenges to coordinating a global response, including navigating diverse legal frameworks to address technology-facilitated human trafficking that transcends borders.   It is often difficult to determine which jurisdiction has authority to investigate and prosecute perpetrators and coordinate international investigation efforts involving multiple countries.   Even when the jurisdiction is established, the necessary evidence gathering and coordination often results in lengthier processes, causing further strain on law enforcement agencies.   Traffickers also take advantage of and operate with impunity due to gaps, inadequacies, or loopholes in laws and regulations to address technology-facilitated trafficking and associated activities.

The lack of sufficient funding for research and training on traffickers’ exploitation of digital tools can leave the anti-trafficking field responding reactively rather than proactively.   Capacity and resources are particularly acute challenges for law enforcement in regions with limited access to advanced technology.  Several technology-based anti-trafficking tools exist for data mining; however, many regions are unable to take advantage of these resources due to a lack of technological infrastructure and digital literacy.   Victims may also find themselves isolated and unable to easily seek help in geographical areas with limited technological capabilities, and poor internet connectivity or coverage may affect their ability to receive information and services from anti-trafficking NGOs in a timely manner.

Data Privacy, Protection, and Access

Data protection, data analysis, and data sharing are crucial methods of using digital technologies to prevent, identify, and reduce instances of human trafficking, but practitioners must consider potential negative effects on the safety and well-being of victims and survivors.   Collecting and sharing data on human trafficking cases, including victims’ personally identifiable information (PII) can be essential for law enforcement and victim support efforts, but could raise serious data privacy concerns for victims and survivors should their information be inadvertently released to the public through data breaches, which has become a common issue with digital technology in general.   NGOs and technology companies often use data mining techniques to support law enforcement in investigating offenses but may lack appropriate security protocols to properly safeguard the data and protect victims’ PII from bad actors.   Different standards for ensuring data privacy and protections across countries and concerns around national security hinder effective information sharing between governments.   Frameworks for data collection, storage, and sharing of personal data are often different, complicating international cooperation.   Governments should consider strengthening digital literacy and infrastructure, where possible, to improve data security standards and procedures, while listening to the recommendations from anti-trafficking stakeholders, including those with lived experiences of trafficking, to assess the best mechanisms for gathering, analyzing, and sharing data related to victims and survivors.    

Encryption & Anonymity

Encryption systems are one way to safeguard data in digital interactions including in web browsing, messaging apps, and financial transactions.   Such systems prevent third parties from accessing data by turning readable data into a scrambled code that can only be recovered by the receiver’s system, ensuring that only authorized parties can access the original data.   Anonymizing technology provides a high level of privacy and obscures the connection between an individual’s online activity and their real identity.   Encryption systems found in many online platforms are designed to protect the privacy and security of all online users; however, these systems and anonymizing technologies such as virtual private networks (VPNs), can also offer protection to bad actors, allowing them to avoid detection and accountability.

As with any crime, heightened anonymity may pose a major challenge for law enforcement and anti-trafficking stakeholders in identifying traffickers and their co-conspirators, whether it is the creator of a fraudulent social media account or author of an online advertisement scam.   Traffickers increasingly benefit from and rely on the protection that digital tools offer as it amplifies an offender’s ability to anonymize themselves through the entire transactional process – from the recruitment and the solicitation to the management of the transactions and relationships to the payment.  Virtual currency has even enabled a distance between those making and receiving payments and the movement of the money.  Traffickers may also hide their IP addresses and encrypt their communications, such as emails, chat messages, and file transfers.   Together this allows greater physical separation between the offender and the offense, impacting the crime itself and law enforcement’s ability to intercede.

Media or Misinformation

The proliferation of social media and online forums have increased the potential for false narratives and misinformation about human trafficking to circulate online and skew public perceptions of the crime.   Even accurate reporting on human trafficking cases and issues may unintentionally minimize the wide range of potential trafficking experiences.   Unfortunately, the most sensationalized and misleading stories tend to attract the most attention and mispresent what human trafficking is while also shifting focus away from more prevalent forms of trafficking and from marginalized populations whose exploitation may not receive the same coverage.   Such reports may also create a singular or limited perception within communities of what human trafficking looks like, perpetuating stereotypes and interfering with prevention efforts or victims’ ability to self-identify.

The Promise of Technology in Monitoring and Combating Human Trafficking

Technology also plays an important role in investigating and countering human trafficking.   Digital technology, including mobile applications, social media campaigns, and online hubs, can be used to further share information, resources, and training on human trafficking.   It can also be used to improve access to online support services for victims, survivors, and vulnerable populations.   Organizations are using data analytic tools to help identify current trends in fraudulent recruitment, map complex supply chains for links to forced labor, and detect emerging human trafficking schemes.   These tools help support information sharing used to bolster identification, investigation, and prosecution efforts by providing means to integrate and analyze data from multiple sources.

Enhancing Education and Outreach Efforts

Digital technology and literacy expand the reach of prevention efforts to raise awareness and educate the public on human trafficking globally.   Given the increase in online activity among children, governments and parents should even further prioritize education around online safety for children and youth, and could take advantage of online tools to inform children of the risks related to the internet.   Fortunately, there are already a number of beneficial training tools for young people using social media and mobile applications, as well as for parents and guardians, that help support early interventions to prevent technology-facilitated trafficking of youth.   One example of how technology is being used for public awareness is through online campaigns including the Can You See Me? campaign administered by A21, a global anti-trafficking organization in the United States, aimed at informing the general public on how to spot signs of human trafficking and where to report it.

Technology is also being used to improve awareness and outreach efforts to support worker engagement and empowerment.   Commonly used messaging apps and social media platforms, as well as specially designed worker engagement and empowerment platforms, are used to educate workers on their labor rights, including the right to organize; access legal and social services; and connect with legitimate employers and jobs.   Some tools also offer responsible employment training for managers, provide secure grievance mechanisms for workers, aggregate worker survey responses, and provide feedback opportunities, allowing workers to share information about their recruitment and work experiences.   One promising example comes from Polaris, an NGO based in the United States.   Through its Nonechka project, Polaris collaborated with technology partner Ulula on a platform that allows farmworkers in Mexico and now in the United States to share their experiences, including information on risky recruitment and employment processes.   This information also helps Polaris formulate prevention strategies, as well as inform workers about their rights, wages, and working conditions and how to access general services locally including emergency, transitional, or long-term services.

Victim Services

Digital technology tools can aid victims during the exit and recovery phases of a human trafficking experience.   Technology can play a pivotal role in victim identification, employing various methods and platforms for finding victims online and allowing for self-reporting exploitation.   For example, the Canadian NGO Center for Child Protection (C3P) operates Project Arachnid , a web crawler that searches for known CSAM.   When such material is detected, C3P sends a notice to the provider asking that the material be removed. The NGO Thorn also has an AI-powered tool that detects CSAM and tools that aid law enforcement in child sex trafficking investigations.   While digital investigative techniques, including those that make use of AI, can assist in trafficking detection, investigation, and successful prosecutions, basic communication tools such as messaging apps, SMS and text, and phone channels also offer lower-tech and straightforward avenues for victims to communicate with service providers in real time.   Successful tools to advance victim services include those that facilitate and increase access to victim resource hotlines, virtual peer community spaces, and financial inclusion resources.   There are also online tools to bolster training and technical assistance for professionals who wish to support victims and survivors during the aftermath of victimization and to navigate the criminal justice system.   Most of these tools are mobile applications and leverage web- and cloud-based solutions for victim services.   The GraceCity App, for example, developed by anti-trafficking advocates in Sacramento, California, is a mobile application that offers victims and survivors details on the community resources in their area.   The app can canvass thousands of first responders and provide users with useful resources including nearby NGOs, medical professionals, social workers, and therapists.   Technologically enhanced interventions can be instrumental in overcoming challenges to victim identification, outreach, and intervention, providing real-time communication channels that are accessible, secure, and more efficient in providing immediate assistance tailored to the individual’s situation and unique needs.

Data Collection and Sharing Efforts

As mentioned earlier, data collection, data analysis, and data sharing are crucial components of using digital technologies to prevent, identify, and reduce instances of human trafficking.   Anti-trafficking stakeholders have created tools and established new initiatives to improve their data collection and sharing to support investigation and prosecution efforts.   For example, social media and communication platforms are rich sources of information for law enforcement investigations, but combing through large-scale datasets can be time consuming and labor intensive.   A diverse group of stakeholders, including governments, international organizations, civil society organizations, private sector businesses, and information technology professionals developed technology tools to assist in anti-trafficking efforts.   These tools help anti-trafficking stakeholders collect and analyze vast amounts of qualitative and quantitative data through techniques such as data mining, machine learning, and natural language processing.   These digital tools not only enhance the utility and speed of traditional data collection methods used for case management and investigative purposes, but also make it easier for anti-trafficking actors to analyze the data to share real-time insights that better equip the field to address and combat trafficking.   Despite this potential, reports show that NGOs have traditionally underutilized such tools due to lack of knowledge, access, expertise, and funding, and more information is needed to better understand barriers to use.    

Anti-trafficking applications can help investigators perform pattern analyses from big-data searches encompassing structured and unstructured data from sources including social media.   These analyses allow investigators to understand traffickers’ online activities as well as their most frequently used platforms and profiles used to target and mislead victims.  For example, the Counter Trafficking Data Collaborative (CTDC), developed by the International Organization for Migration, brings together anti-trafficking organizations from around the world to make human trafficking data publicly available in a central, accessible online platform.   The goal of CTDC is to break down information sharing barriers and equip the anti-trafficking community with reliable data. CTDC offers primary, individual-level data scrubbed of personally identifiable information on victims of human trafficking that can be used to track human trafficking trends globally.

From identifying trafficking patterns to increasing accountability within supply chains to prevent forced labor, the multifaceted nature of data collection and sharing requires multidisciplinary partnerships for the benefits of data-related solutions to fully materialize.   Data collection and sharing among several anti-trafficking stakeholders is key to effectively developing anti-trafficking policies, identifying victims, prosecuting the perpetrators, and mapping where and how traffickers and transnational criminal networks operate.   Collaboration on data collection and sharing should particularly be encouraged between sectors and stakeholders equipped with capabilities to collect data and gather intelligence and insights.   Such stakeholders should include NGOs, survivor-led organizations, individuals with lived experience of human trafficking, and intelligence or investigative agencies.   The Traffik Analysis Hub is another example of a global solution that supports joint analysis of large AI-generated data sets, providing partners with the ability to pool data assets to generate new insights into patterns and hotspots of trafficking incidents.   Information from the Traffik Analysis Hub, which was developed with the support of IBM, is also shared with law enforcement so actions can be taken to disrupt trafficking operations.   The ability to use large quantities of data and data analytics also helps to minimize the use of individual victim information and victim testimony to support trafficking prosecutions.

However, the collection and analysis of large data sets present several significant risks and challenges including privacy and data security concerns, misuse of data, and bias and inaccuracies that could result from reliance on large data collections.   To mitigate these risks, it is crucial to implement data protection measures to ensure ethical data collection practices and protect individual’s right to privacy.

  • Lessons Learned and Looking Ahead

The Role of Government

Governments have the responsibility to regulate the use of technology, including in anti-trafficking efforts, such as disincentivizing the abuse of online resources for trafficking.   Efforts to legislate and regulate tech companies to better prevent and address human trafficking will have broader impacts in areas such as privacy, security, and innovation, so careful consideration with a wide range of stakeholders will be needed.

Right now, government approaches to addressing emerging issues in the digital era continue to be fragmented, in part due to the scale and speed at which digital technology evolves.   Inconsistent policies make it difficult to combat tech-facilitated crimes due to their transnational and multi-jurisdictional elements.   Some governments are recognizing the importance of regulating digital platforms to protect and further national security, economic development, and human rights priorities and many have begun developing policies around the production, deployment, and use of digital technologies.   Collaboration and coordination at the international and national level will make it harder for perpetrators to continue their illicit activities.

Globally, government investment in digital technologies for anti-trafficking efforts remains low, despite significant potential.   Private sector and civil society stakeholders, including those with lived experience, will be critical to identifying additional government-funded research and development necessary to channel the positive aspects of technology and protect those who use it.   An OSCE and Tech Against Trafficking analysis found that out of 305 technology tools readily available to combat human trafficking, only 9 percent were developed through government investments.   Consideration should also be given as to how best to develop and share existing tech tools in regions of the world that lack such tools.    

The Role of Law Enforcement

Law enforcement agencies are tasked with combating technology-facilitated human trafficking by monitoring online platforms, investigating suspicious activity, and prosecuting perpetrators.   Law enforcement agencies can continuously look for new ways to proactively investigate trafficking cases by harnessing technological innovations to collect evidentiary material.   For proactive investigations, agencies can focus on increasing internal capacity to integrate data analytics and artificial intelligence tools into casework, as well as collaborate and coordinate with NGOs and technology companies in tool development, training, and information sharing – with due regard to privacy safeguards.

Law enforcement agencies have found ways to leverage technology to help identify, track, and monitor illicit activity by following its digital footprint.   A digital footprint could include online activity, from websites visited to social media posts published, and can help paint a clearer picture of a trafficker’s identity, location, and criminal activity.   Such publicly available digital evidence is often helpful in building a trafficking case.

Examples of law enforcement leveraging online data to support criminal investigations include:

  • In September 2023, The Netherlands, supported by EUROPOL, coordinated a 3-day investigation targeting online criminal activities that enable human trafficking.   Law enforcement from 26 countries alongside representatives from European Labor Authority, European Police College (CEPOL), INTERPOL, OSCE, and International Justice Mission, focused on identifying online platforms and social media to recruit victims for sexual and labor exploitation.   This led to identifying 11 suspected human traffickers and 45 potential victims.
  • In 2023, Operation Synergia led by INTERPOL, targeted human trafficking rings linked to cyber scam centers.   Partnering with a leading creator of cybersecurity technology, Group-IB’s Threat Intelligence and High-Tech Crime Investigation teams collected and shared information with INTERPOL and other law enforcement agencies to locate over 2,400 IP addresses associated with cybercrime, leading to the removal of the servers.   Over 60 law enforcement agencies from 50 countries participated in the search and seizure of 1,300 malicious servers and electronic devices, shutting down 70 percent of identified cybercrime command servers while the remaining 30 percent are under investigation.

Law enforcement agencies must be better resourced to combat technology-facilitated human trafficking or use technology for human trafficking investigations.   This can be achieved through greater investment in staff, training, and software.   Law enforcement officers must be trained on monitoring and evaluating online platforms and developing technical knowledge.   Law enforcement agencies can deepen their capabilities by establishing cybercrime units tasked with data analysis and decryption technology.   Cooperation protocols with NGO and private sector partners will further data sharing and the design and deployment of new tools that are victim-centric and trauma- and survivor-informed.   Multilateral knowledge exchange should also be considered when developing technology tools to prevent traffickers from exploiting the gaps in capacity and legislation between law enforcement agencies.   Governments should also focus on implementation of the UN Convention against Transnational Organized Crime and its Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children to address legislation gaps.   Lastly, law enforcement agencies with access to victims’ personal data must have protection standards in place on the collection and storage of such personal data.

The Role of the Financial Sector

The financial sector also plays a vital role in combating human trafficking.   According to the International Labour Organization, human trafficking is responsible for an estimated $236 billion in illicit profits annually.   All forms of currency, including both traditional and digital assets (e.g. cryptocurrency), can be laundered, requiring a multidimensional approach involving legislative measures, collaboration between justice and financial sectors, technological innovations, and ethical considerations to detect their use in criminal enterprises.   The financial sector’s role extends beyond upholding regulatory frameworks, often guided by promising practices in the area of corporate responsibility.  As illicit proceeds from human trafficking can intersect with formal financial systems at any stage of a human trafficking crime, it is essential that financial institutions proactively manage the risk of technology-facilitated human trafficking and train staff on the financial indicators and techniques used by human traffickers to launder money.   Coordination in this area should also include financial institutions working with law enforcement, technology companies, and survivors to inform their efforts, including on the development of training programs to enhance the ability of frontline staff and other industry professionals to detect transactions connected to human trafficking, how and when to intervene, and how to determine when a third party is benefitting from the exploitation of another.

Globally, the Financial Action Task Force (FATF) is the standard-setting body for anti-money laundering and countering the financing of terrorism and weapons proliferation.   More than 200 countries have agreed to implement FATF recommendations, which provide guidance for member countries to identify, assess, and understand money laundering and illicit finance risks and to mitigate those risks.   Since 2019, the FATF has included guidance on how to assess and mitigate risks associated with digital assets and digital asset service providers, including recommendations on how member jurisdictions should regulate cryptocurrency transactions.   Countries are encouraged to adapt FATF recommendations to their specific context to establish or enhance efforts to tackle illicit financial transactions.

Following digital financial transactions human traffickers leave behind can identify broader criminal networks and make it more difficult to profit from human trafficking.   For this reason, responsible innovation in technology and proactive partnerships between governments, financial institutions, law enforcement, and civil society experts, including those with lived experiences are an important part of identifying illicit financial activity associated with human trafficking and safeguarding financial systems against human trafficking, money laundering, terrorist financing, and other serious financial crimes.

The Role of NGOs

NGOs are one of the primary users and drivers of the development of anti-trafficking technological tools, algorithms, and programs and use digital technology to provide survivors easier access to resources and support services such as online counseling and helplines.   NGOs are also well-positioned to build strong partnerships with and bridge the gap between technology companies, governments, survivors, and community organizations to enhance the creation and broaden the use of essential anti-trafficking application services.   NGOs can use these relationships to advocate for and consult on the creation of standardized response frameworks, data privacy for victims when using anti-trafficking technology tools, and solutions to other emerging concerns around technology.    

A result of a partnership between NGOs and international organizations (IOs) to advance work under the UN’s Global Compact on Decent Work in Global Supply Chains, the Interactive Map for Businesses of Anti-Human Trafficking Organizations was developed to be a user-friendly repository database that tracks global and local initiatives and organizations that businesses can partner with on anti-trafficking efforts.   The map provides NGOs an opportunity to optimize coordination, research, awareness, and prevention efforts through the ability to identify specific industry initiatives to combat human trafficking via a filter tool that organizes data based on industry, geography, or issue, among others.

The Role of the Technology Industry

The technology industry, while providing many benefits can also inadvertently create environments that facilitate trafficking and other crimes, including by creating a space that facilitates unsupervised access to children.  Many companies acknowledge that the popularity and simplicity of user-friendly application services contribute to unsafe environments by providing traffickers with easy access to communicate, advertise, and coordinate illicit activity. Some technology companies have taken steps to address these challenges, but ongoing efforts are needed to enhance security measures, improve content moderation, and collaborate with law enforcement to prevent technology from being used by bad actors for illicit activities. Technology can play several roles to include using data and algorithm tools to detect human trafficking patterns, identify suspicious and illicit activity, and report such activity to law enforcement.   Technology companies play a pivotal role in protecting victims and vulnerable individuals from being exploited through the use of their online platforms and must be part of the solution to combat human trafficking.

Some technology companies are increasingly investing in better language models and machine learning to allow computers to learn from and make predictions based on data trends.   These tools are a useful resource as they may provide law enforcement agencies with powerful tools to more efficiently target illicit activity and possible cases for investigation, but they are not required.   Language models can detect, translate, and categorize key words used by traffickers to identify trafficking communication patterns.   It can be used to aid international investigations and target traffickers since they often recruit individuals in different countries primarily communicating through technology and internet platforms in the victims’ native language.   Alongside language models, other machine learning tools have the ability to cross reference various data sets, such as combining law enforcement data and transit trends, to help stakeholders formulate specific algorithms that can trace traffickers’ patterns.   These tools can enhance collaboration between law enforcement agencies and other stakeholders, as well as quickly close the gap for countries that may not have established effective tools to track or investigate human trafficking.   As developers continue to build and enhance anti-trafficking applications for protection, prevention, or prosecution functions, they must be designed to tackle the unique challenges and scenarios that arise in the context of human trafficking.

Regardless of the progress provided by technology tools, it is crucial that anti-trafficking stakeholders be cautious of becoming overly reliant on using AI and facial recognition technology to identify victims of human trafficking and the traffickers.   These tools should enhance, not replace, existing methods.   Developers, policymakers, and anti-trafficking leaders seeking to improve anti-trafficking efforts with AI and facial recognition tools should prioritize establishing data privacy rights and ensuring individuals’ information is protected throughout data-sharing processes.

Taking Action: Considerations for Anti-Trafficking Stakeholders

Harnessing technology to advance the shared goal of governments, law enforcement actors, technology companies, and civil society to eliminate human trafficking will require proactive efforts by all actors to resolve the complex, often contradictory byproducts of technological progress.   Governments can adopt policies and legislation that recognize human traffickers’ use of technology and incentivize the positive use of technology tools to investigate and counter human trafficking, and must coordinate implementation of these policies through collaboration with the technology sector, the financial sector, anti-trafficking NGOs, and lived experience experts who can help build capacity to monitor online spaces, train staff, develop technology tools, and cultivate technical expertise.   Law enforcement entities can use technology to conduct data analytics on traffickers, their connections, and their modus operandi to inform human trafficking investigations and related money laundering activities, bolster the identification of victims online, and enhance safety nets.   Governments can also strengthen data security from unauthorized access to better protect victims and investigations and find technology-based solutions that further privacy, safety, and trust.   Multilateral forums offer important venues for governments to share best practices and develop new policies and standards that uphold current international frameworks but are also tailored to regional and local trafficking situations and existing technological capabilities.

NGOs can advocate for policies and tech solutions that empower vulnerable individuals, strengthen access to services, advance digital learning, and further privacy protections.   Local communities, NGOs, and those with lived experience know current trafficking trends and how technology is being used to facilitate crimes, and thus can recommend ways to enhance trauma-informed and victim-centric tech solutions and ways to get tech tools in the hands of those who most need them.   The technology sector should work to ensure their online platforms are being used for legitimate purposes and ensure privacy and safety for users.   The technology sector can also invest in new technologies that include detecting and countering child sexual abuse material, livestreaming trafficking offenses, and fraudulent cyber scams or job offers among other crimes occurring on their platforms.   Governments, anti-trafficking NGOs, companies, and innovators can also employ routine audits of technology tools as digital technologies evolve to limit negative consequences and better guarantee efficient, sustainable means to address human trafficking.

Collaborative efforts allow all relevant parties to inform and promote best practices for the responsible and safe use of technology by a variety of actors, including individuals vulnerable to technology-facilitated trafficking.   The challenge is immense, but political will, resource investments, innovation, and partnerships will help prevent traffickers’ use of technology for exploitation, and instead amplify and scale the best applications that assist all anti-trafficking stakeholders in meeting our obligations to combat the newest continuously evolving aspects of this pernicious crime.

  • Understanding Human Trafficking

“Trafficking in persons” and “human trafficking” are umbrella terms—often used interchangeably—to refer to a crime whereby traffickers exploit and profit at the expense of adults or children by compelling them to perform labor or engage in commercial sex.  When a person younger than 18 is used to perform a commercial sex act, it is a crime regardless of whether there is any force, fraud, or coercion involved.

The United States recognizes two primary forms of trafficking in persons:  forced labor and sex trafficking.  The basic meaning of these forms of human trafficking and some unique characteristics of each are set forth below, followed by several key principles and concepts that relate to all forms of human trafficking.

More than 180 nations have ratified or acceded to the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons (the UN TIP Protocol), which defines trafficking in persons and contains obligations to prevent and combat the crime.

The United States’ TVPA and the UN TIP Protocol contain similar definitions of human trafficking.  The elements of both definitions can be described using a three-element framework focused on the trafficker’s 1) acts; 2) means; and 3) purpose.  All three elements are essential to form a human trafficking violation.

Forced Labor

Forced Labor, sometimes also referred to as labor trafficking, encompasses the range of activities involved when a person uses force, fraud, or coercion to exploit the labor or services of another person.

The  “acts”  element of forced labor is met when the trafficker recruits, harbors, transports, provides, or obtains a person for labor or services.

The  “means”  element of forced labor includes a trafficker’s use of force, fraud, or coercion.  The coercive scheme can include threats of force, debt manipulation, withholding of pay, confiscation of identity documents, psychological coercion, reputational harm, manipulation of the use of addictive substances, threats to other people, or other forms of coercion.

The  “purpose”  element focuses on the perpetrator’s goal to exploit a person’s labor or services.  There is no limit on the location or type of industry.  Traffickers can commit this crime in any sector or setting, whether legal or illicit, including but not limited to agricultural fields, factories, restaurants, hotels, massage parlors, retail stores, fishing vessels, mines, private homes, or drug trafficking operations.

All three elements are essential to constitute the crime of forced labor.

There are certain types of forced labor that are frequently distinguished for emphasis or because they are widespread:

Domestic Servitude

“Domestic servitude” is a form of forced labor in which the trafficker requires a victim to perform work in a private residence.  Such circumstances create unique vulnerabilities.   Domestic workers are often isolated and may work alone in a house.  Their employer often controls their access to food, transportation, and housing.  What happens in a private residence is hidden from the world – including from law enforcement and labor inspectors – resulting in barriers to victim identification.  Foreign domestic workers are particularly vulnerable to abuse due to language and cultural barriers, as well as a lack of community ties.  Some perpetrators use these types of conditions as part of their coercive schemes to compel the labor of domestic workers with little risk of detection.

Forced Child Labor

The term “forced child labor” describes forced labor schemes in which traffickers compel children to work.  Traffickers often target children because they are more vulnerable.  Although some children may legally engage in certain forms of work, forcing or coercing children to work remains illegal.  Forms of slavery or slavery-like practices – including the sale of children, forced or compulsory child labor, and debt bondage and serfdom of children – continue to exist, despite legal prohibitions and widespread condemnation.  Some indicators of forced labor of a child include situations in which the child appears to be in the custody of a non-family member and the child’s work financially benefits someone outside the child’s family; or the denial of food, rest, or schooling to a child who is working.

Sex Trafficking

Sex trafficking encompasses the range of activities involved when a trafficker uses force, fraud, or coercion to compel another person to engage in a commercial sex act or causes a child to engage in a commercial sex act.

The crime of sex trafficking is also understood through the “acts,” “means,” and “purpose” framework.  All three elements are required to establish a sex trafficking crime (except in the case of child sex trafficking where the means are irrelevant).

The  “acts”  element of sex trafficking is met when a trafficker recruits, harbors, transports, provides, obtains, patronizes, or solicits another person to engage in commercial sex.

The  “means”  element of sex trafficking occurs when a trafficker uses force, fraud, or coercion.  Coercion in the case of sex trafficking includes the broad array of means included in the forced labor definition.  These can include threats of serious harm, psychological harm, reputational harm, threats to others, and debt manipulation.

The  “purpose”  element is a commercial sex act.  Sex trafficking can take place in private homes, massage parlors, hotels, or brothels, among other locations, as well as on the internet.

Child Sex Trafficking

In cases where an individual engages in any of the specified “acts” with a child (under the age of 18), the means element is irrelevant regardless of whether evidence of force, fraud, or coercion exists.  The use of children in commercial sex is prohibited by law in the United States and most countries around the world.

Key Principles and Concepts

These key principles and concepts relate to all forms of trafficking in persons, including forced labor and sex trafficking.

Human trafficking can take place even if the victim initially consented to providing labor, services, or commercial sex acts.  The analysis is primarily focused on the trafficker’s conduct and not that of the victim.  A trafficker can target a victim after a victim applies for a job or migrates to earn a living.  The trafficker’s exploitative scheme is what matters, not a victim’s prior consent or ability to meaningfully consent thereafter.  Likewise, in a sex trafficking case, an adult victim’s initial willingness to engage in commercial sex acts is not relevant where a perpetrator subsequently uses force, fraud, or coercion to exploit the victim and cause them to continue engaging in the same acts.  In the case of child sex trafficking, the consent of the victim is never relevant as a child cannot legally consent to commercial sex.

Neither U.S. law nor international law requires that a trafficker or victim move across a border for a human trafficking offense to take place.  Trafficking in persons is a crime of exploitation and coercion, and not movement.  Traffickers can use schemes that take victims hundreds of miles away from their homes or exploit them in the same neighborhoods where they were born.

Debt Bondage

“Debt bondage” is focused on human trafficking crimes in which the trafficker’s primary means of coercion is debt manipulation.  U.S. law prohibits perpetrators from using debts as part of their scheme, plan, or pattern to compel a person to work or engage in commercial sex.  Traffickers target some individuals with an initial debt assumed willingly as a condition of future employment, while in certain countries traffickers tell individuals they “inherited” the debt from relatives.  Traffickers can also manipulate debts after the economic relationship begins by withholding earnings or forcing the victim to assume debts for expenses like food, housing, or transportation.  They can also manipulate debts a victim owes to other people.  When traffickers use debts as a means to compel labor or commercial sex, they have committed a crime.

The Non-Punishment Principle 

A victim-centered and trauma-informed approach is key to successful anti-trafficking efforts.  A central tenet of such an approach is that victims of trafficking should not be inappropriately penalized solely for unlawful acts they committed as a direct result of being trafficked.  Effective implementation of the “non-punishment principle,” as it is increasingly referred to, not only requires recognizing and embracing the principle in regional and national laws, but also increasing proactive victim identification.

State-Sponsored Human Trafficking

While the TVPA and UN TIP Protocol call on governments to proactively address trafficking crimes, some governments are part of the problem, directly compelling their citizens into sexual slavery or forced labor schemes.  From forced labor in local or national public work projects, military operations, and economically important sectors, or as part of government-funded projects or missions abroad, officials use their power to exploit their nationals.  To extract this work, governments coerce by threatening the withdrawal of public benefits, withholding salaries, failing to adhere to limits on national service, manipulating the lack of legal status of stateless individuals and members of minority groups, threatening to punish family members, or conditioning services or freedom of movement on labor or sex.  In 2019, Congress amended the TVPA to acknowledge that governments can also act as traffickers, referring specifically to a “government policy or pattern” of human trafficking, trafficking in government-funded programs, forced labor in government-affiliated medical services or other sectors, sexual slavery in government camps, or the employment or recruitment of child soldiers.

Unlawful Recruitment or Use of Child Soldiers

Another manifestation of human trafficking occurs when government forces or any non-state armed group unlawfully recruits or uses children – through force, fraud, or coercion – as soldiers or for labor or services in conflict situations.  Children are also used as sex slaves.  Sexual slavery, as referred to here, occurs when armed groups force or coerce children to “marry” or be raped by commanders or combatants.  Both male and female children are often sexually abused or exploited by members of armed groups and suffer the same types of devastating physical and psychological consequences associated with sex trafficking.

Accountability in Supply Chains

Forced labor is well documented in the private economy, particularly in agriculture, fishing, manufacturing, construction, and domestic work; but no sector is immune.  Sex trafficking occurs in several industries as well.  Most well-known is the hospitality industry, but the crime also occurs in connection with extractive industries where activities are often remote and lack meaningful government presence.  Governments should hold all entities, including businesses, accountable for human trafficking.  In some countries, the law provides for corporate accountability in both the civil and criminal justice systems.  U.S. law provides such liability for any legal person, including a business that benefits financially from its involvement in a human trafficking scheme, provided that the business knew or should have known of the scheme.

Topics of Special Interest

  • Trafficking in Persons for the Purpose of Organ Removal

Trafficking in persons for the purpose of organ removal is one of the least reported and least understood forms of trafficking – but one that experts believe may be growing.  Like sex trafficking and labor trafficking, it is ultimately a crime that exploits human beings for economic profit.  Trafficking in persons for the purpose of organ removal is “a form of trafficking in which an individual is exploited for their organ, including by coercion, deception and abuse of a position of vulnerability.”  The crime is sometimes confused with organ trafficking; however, organ trafficking refers more broadly to the illicit trade or exchange of organs for financial or other material gain.  In organ trafficking, the focus is on the organ itself; conversely, with trafficking in persons for the purpose of organ removal, the focus is on the individual.  The key global anti-trafficking instrument, the Palermo Protocol, defines exploitation to include at a minimum “the removal of organs,” alongside sexual exploitation, forced labor, and slavery or slavery-like practices.

Often, in cases of trafficking in persons for the purpose of organ removal, would-be donors are tricked into organ donation.  Common deceptions include being told human beings have three kidneys or that kidneys regenerate after being removed, or being falsely told they will experience no negative side effects from a kidney removal (in fact, kidney donors may face serious lifelong medical challenges and be unable to work).  Although kidneys are the most common organ involved, other organs and tissues, such as livers, corneas, or skin, are also sought, although notably the Palermo Protocol’s definition covers only exploitation for the removal of organs, not of tissues or cells.  Victims may not be paid at all, or they may receive some payment; importantly, an individual can still be a victim of trafficking in persons or other human rights abuses even if they received some form of payment.

The 2022 UNODC Global Report on Trafficking in Persons noted trafficking in persons for the purpose of organ removal constituted only 0.2 percent of detected victims of trafficking compared to the much higher numbers for sex trafficking and forced labor.  UNODC has warned “existing barriers to reporting suggest that the full scale of this phenomenon is not yet known.”  The report also noted an uptick in cases (from 25 in 2017 to 40 in 2018), though the overall numbers are small.  Between 2008 and 2022, UNODC reported 700 victims of trafficking in persons for the purpose of organ removal while noting “the scale of the problem is likely to be much larger.”

Trafficking in persons for the purpose of organ removal is difficult to detect for several reasons.  Data-collection efforts are scarce, and some instances of trafficking in persons for the purpose of organ removal may be mistakenly classified or prosecuted as organ trafficking.  Moreover, unlike sex trafficking and labor trafficking, which can take place over months or years, trafficking in persons for the purpose of organ removal usually involves a brief, often one-time, interaction.  Like other forms of trafficking, transactions have increasingly shifted online and become more sophisticated, facilitating the emergence of smaller networks, and even independent brokers and suppliers, which may be more difficult to track.

Both the 2020 and 2022 UNODC Global Report on Trafficking in Persons and a 2021 INTERPOL report suggest North Africa and the Middle East have the highest share of detected victims, in part due to the prevalence of large vulnerable communities, limited access to medical care, and corruption.  The media and some NGOs have also reported instances of trafficking in persons for the purpose of organ removal for ritual purposes.  However, instances of trafficking in persons for the purpose of organ removal can occur worldwide.  In a case recently prosecuted in the United Kingdom, the victim was recruited in Nigeria and brought to London, where the organ removal was to take place (see inset box for additional information).  In another case reported by the BBC in late 2023, revealing the connection between organ trafficking and trafficking in persons for the purpose of organ removal, Pakistani police arrested eight members of an organ-trafficking ring that “lure[d] vulnerable patients from hospitals” and conducted transplants “often without the patient knowing;” several people died from these procedures.

The government of the People’s Republic of China, in particular, has been accused of systematically forcibly removing organs from political prisoners.  For example, a group of UN human rights experts noted in 2021:

Forced organ harvesting in China appears to be targeting specific ethnic, linguistic, or religious minorities held in detention, often without being explained the reasons for arrest or given arrest warrants, at different locations.  We are deeply concerned by reports of discriminatory treatment of the prisoners or detainees based on their ethnicity and religion or belief.

(Note:  forced organ harvesting is not a term defined in the Palermo Protocol, but the phrase is commonly used to describe trafficking in persons for the purpose of organ removal.)

While there is a need for additional studies and reporting to thoroughly assess the geographic and numeric scope of trafficking in persons for the purpose of organ removal, stakeholders are taking steps to attempt to address the issue.  A number of regional instruments, including the Council of Europe Convention against Trafficking in Human Organs, the Council of Europe Convention on Action against Trafficking in Human Beings, and the ASEAN Convention against Trafficking in Persons, Especially Women and Children, recognize organ removal as a form of trafficking-related exploitation.

Experts have also proposed ideas to increase the supply of legally donated organs, with the intention of making trafficking in persons for the purpose of organ removal and organ trafficking less lucrative.  These ideas include transitioning deceased organ donation from an opt-in to an opt-out system; implementing paired exchanges matching donors and patients; creating awareness campaigns targeted at potential donors, including addressing barriers to altruistic organ donation and providing guidance on how to prevent trafficking in persons for the purpose of organ removal; building the capacity of law enforcement to detect and investigate these cases; and improving transparency and reporting around transplantation.

Twenty-one-year-old “Daniel” (not his real name) scraped out a living selling mobile-phone accessories at an outdoor street market in Lagos, Nigeria, but he thought his luck took a turn when he was offered a “life-changing opportunity” to work in the United Kingdom.   The people he believed were his employers instructed him to take a blood test, which he thought was required to secure a visa.   The people he had been working with put him on a flight and confiscated his passport.   Within days of arriving in London, Daniel was taken to the Royal Free Hospital, where doctors discussed the risks of the upcoming “operation” – something Daniel knew nothing about.   Seeing his confusion, the doctors sent Daniel away – but did not notify authorities.   Later, Daniel overheard a conversation among those who had brought Daniel to the UK speaking about sending him back to Nigeria to remove his kidney.   Scared, Daniel escaped, sleeping on the streets for several days until walking into a police station and telling his story.   Daniel’s bravery eventually led to the UK’s first prosecution of – and convictions for – human trafficking for the purpose of organ removal.   A prominent Nigerian politician and his wife who had arranged the trafficking scheme to provide their daughter with a kidney transplant, as well as a Nigerian doctor, were convicted in 2023.

This story was published by the BBC, Organ Harvesting:   Trafficked for His Kidney and Now Forced into Hiding , June 26, 2023 ( https://www.bbc.com/news/65960515 ); for additional details, see the Crown Prosecution Service, Updated with Sentence: Senior Nigerian Politician Jailed Over Illegal UK Organ-Harvesting Plot , May 5, 2023 ( https://www.cps.gov.uk/cps/news/updated-sentence-senior-nigerian-politician-jailed-over-illegal-uk-organ-harvesting-plot ).

  • Connecting the Dots:  Preventing Forced Labor by Empowering Workers

Forced labor, a form of human trafficking, is universally condemned yet prevalent in nearly every industry globally.  The International Labour Organization (ILO) reports forced labor has grown in recent years – with no region of the world or private sector industry spared – and the majority of forced labor takes place in the private economy, meaning forced labor is connected to global supply chains.  These facts demand a re-examination of current efforts to prevent and address forced labor, including the need to elevate the voice and agency of workers and place them at the center of prevention efforts through strategic partnerships.  In addition, particular focus should be placed on vulnerable populations, such as migrant workers.  ILO research shows the rates of forced labor among migrant workers are higher if migration is irregular or poorly governed, or where recruitment practices are unfair or unethical.

Although prosecuting specific traffickers and assisting individual victims are critical for governments combating forced labor, successful interventions to prevent forced labor require a range of stakeholders willing to visualize and address broader systemic issues centered on worker’s labor rights, including those of migrant workers, as well as supply chain power imbalances.  For governments, this may require additional resources and oversight of workplaces, especially in key sectors where forced labor is often present; better monitoring of the labor recruitment industry; increased outreach to and protections for migrant workers; and improved screening measures by well-trained officials targeting populations at greater risk of exploitation.  For the private sector, it will mean proactively supporting workers and their ability to advocate for themselves, setting clear expectations of suppliers, and rooting out practices that create environments ripe for exploitation.

Worker-led Approaches to Prevent Forced Labor 

Over time, policymakers, academics, and other stakeholders have expanded their thinking to encompass worker-led approaches to address the vulnerabilities of workers and prevent forced labor.  Such approaches include advancing labor rights and standards – including freedom of association, collective bargaining, and the remediation of labor rights abuses – as well as worker-driven approaches that include migrants.  Research has demonstrated workers are most vulnerable to forced labor if they do not know their rights, are excluded from labor protection laws, and lack access to grievance mechanisms.  Workers in the informal sector and women and girls, who often face gender-based violence and harassment in the workplace, can be particularly vulnerable.  One of the most effective ways to prevent worker exploitation is to guarantee workers’ full rights to freedom of association and collective bargaining.  Independent and democratic labor unions, led by workers, are best able to represent workers’ collective interests at multiple levels, including at the national, subnational, regional, and international levels.  Collaborating with local workers, regional international organizations, and global union federations, these unions can reach the most vulnerable workers, organize across a labor sector, and advocate for key policy changes, including responsible migration management.  As a result, they are well positioned to engage powerful transnational companies to address forced labor in their supply chains.

According to ILO’s Director of the Bureau for Workers’ Activities, there have been positive developments over time with unions reaching outside of their traditional base to include the unionization of self-employed workers.  Many unions have also expanded to include more informal economy, migrant, and domestic workers, which is key as many of these workers are governed by a variety of working arrangements, including fixed-term and temporary contracts.

This diversification of representation is important as unions allow workers to negotiate for better working conditions, influence the laws and policies that impact them, and remediate labor rights abuses.  Unions play a pivotal role in securing legislated labor protections and rights, such as legally entitled wages and benefits, occupational safety and health protections, overtime pay, and medical leave.  Union-led efforts help raise the wages for the lowest paid and least skilled workers and lead to fewer hours of unpaid overtime work.  Unions play crucial roles in identifying labor rights abuses and enforcing rights on the job.  One of the most effective ways to prevent the exploitation of migrant workers is by guaranteeing their right to join unions in destination countries.  The multiplier impact is notable, as industries with strong union representation tend to have lower levels of labor rights abuse, the worst forms of child labor, and forced labor.

Where there is an absence of unions, there at least should be effective, secure mechanisms for worker communication and grievances.   Governments should strongly encourage employers to provide mechanisms so workers can advocate for their rights, discuss workplace issues of concern and interest, and communicate grievances, even if that takes place outside a formal union mechanism.  Such mechanisms are essential to preventing forced labor, as they position workers, including migrant workers, to better protect themselves against coercion, deception, discrimination, and other forms of exploitation.

Promising Practices in Improving Labor Conditions 

Several examples stand out as raising labor conditions for workers.  

Dindigul Agreement, India

Indian women and the Dalit-worker led union Tamil Nadu Textile and Common Labor Union (TTCU) signed in April 2022 a historic agreement with clothing and textile manufacturers and major fashion companies to end gender-based violence and harassment at factories in the southern state of Tamil Nadu.  This enforceable brand agreement resulted in multinational companies committing to support a worker- or union-led program at certain factories or worksites.  An assessment a year later by the multi-stakeholder oversight committee found that the workers are now effectively able to detect, remediate, and prevent gender-based violence and harassment.  In addition, the TTCU has conducted peer education training of more than 2,000 workers and management, held more than 30 meetings with management to resolve grievances, and recruited 58 workers as monitors to help remediate gender-based violence and harassment throughout the factory units.

Freedom of Association for Garment Workers, Honduras 

In the decade that has followed Honduran workers signing an agreement with major brand Fruit of the Loom, close to 50 percent of all Honduran garment workers are now employed at a factory where an independent union represents the workforce.  As a result of this signed collective bargaining agreement, workers have won increased wages and benefits and witnessed a reduction in verbal harassment and gender-based violence.

While unionization rates vary considerably across the globe, the ILO notes other encouraging examples.  In Uzbekistan, trade unions have organized seasonal workers and facilitated dual affiliation to different unions in other countries.  In Moldova, unions have begun to establish agreements with unions in destination countries so that migrants have protection when working abroad .  In Benin, Botswana, and Mauritius, trade unions have set up Joint Trade Union Councils, which have drawn up joint declarations, charters, and protocols on the modalities of working together in national social dialogue fora.  In Lithuania and Ukraine, unions have established structures of cross-border collaboration to improve the recruitment and representation of truck drivers in both countries.  

Overall, research has also shown that unionization has spillover effects that extend beyond union workers.  Competition means workers at nonunionized firms also often see increased wages and improved workplace safety norms.  Union members improve communities through heightened civic engagement and increased voter rates.  Unions can also boost business’ productivity by giving experienced workers more input into decisions that design better, more cost-effective workplace procedures.

Milestones, Momentum, and Motivation   

Over the last several years, government and private sector attention has become focused on resilient supply chains, and there are increasing supply chain transparency and due diligence policies, regulations, and laws globally.  In addition, various initiatives have been developed to raise the importance of workers’ agency.  It is notable that flower-sector leader Bloomia’s entire cut-flower supply chain, which encompasses farms in the United States, Chile, and South Africa, will now be certified for human rights protections by the Fair Food Program, pioneers in the worker-driven social responsibility model with its partnerships among retailers, growers, and workers.  Combined, the Partnership for Workers‘ Rights, launched by the United States and Brazil at the 2023 UN General Assembly; the Multilateral Partnership for Worker Organizing, Empowerment, and Rights (M-POWER), which is part of the U.S. Presidential Initiative for Democratic Renewal; and the 2023 U.S. Presidential Memorandum on Advancing Worker Empowerment, Rights, and High Labor Standards present a unique opportunity to proactively advance worker empowerment in the short and long term while simultaneously preventing labor rights violations and abuses, especially forced labor.  The independent UN Special Rapporteur on Contemporary Forms of Slavery made a key theme for 2024 the role of trade unions and worker organizations in preventing contemporary forms of slavery.

The timing is ideal for all stakeholders committed to preventing forced labor to fully embrace the importance of supporting, elevating, and improving labor standards, bringing workers’ voices to the policy formulation and decision-making table, and working to help the public and private sector enforce rules against unfair labor practices.  Governments should take every step to use a whole-of-government approach to advance worker rights and address gaps in labor rights protection and compliance, including for migrant workers; the private sector should see free and fair unions as critical partners in competing in the global economy while protecting workers; and other civil society  stakeholders should ensure that workers’ voices are incorporated early and often, especially when their equities are at stake.

  • Human Trafficking in Cuba’s Labor Export Program

Each year, the Cuban government sends tens of thousands of workers around the globe under multi-year cooperation agreements negotiated with receiving countries.  While medical missions remain the most prevalent, the Cuban government also profited from other similarly coercive labor export programs, including those involving teachers, artists, athletes and coaches, engineers, forestry technicians, and nearly 7,000 merchant mariners worldwide.    According to a report published by the Cuban government, by the end of 2023, there were more than 22,000 government-affiliated Cuban workers in over 53 countries, and medical professionals composed 75 percent of its exported workforce.  The COVID-19 pandemic increased the need for medical workers in many places around the world, and the Cuban government used the opportunity to expand its reach by increasing the number of its medical personnel abroad through the Henry Reeve Brigades, which Cuba first initiated in 2005 to respond to natural disasters and epidemics.  Experts estimate the Cuban government collects $6 billion to $8 billion annually from its export of services, which includes the medical missions.  The labor export program remains the largest foreign revenue source for the Cuban government.

There are serious concerns with Cuba’s recruitment and retention practices surrounding the labor export program.  While the conditions of each international labor mission vary from country to country, the Cuban government subjects all government-affiliated workers to the same coercive laws.  Cuba has a government policy or pattern to profit from forced labor in the labor export program, which includes foreign medical missions.  The Cuban government labels workers who leave the program without completing it as “deserters,” a category that under Cuban immigration law deems them as “undesirable.”  The government bans workers labeled as “deserters” and “undesirables” from returning to Cuba for eight years, preventing them from visiting their families in Cuba.  It categorizes Cuban nationals who do not return to the country within 24 months as having “emigrated.”  Individuals who emigrate lose all their citizen protections, rights under Cuban law, and any property they left behind.  These government policies and legal provisions, taken together, coerce workers and punish those seeking to exercise freedom of movement.  According to credible sources, by 2021, the Cuban government had sanctioned 40,000 professionals under these provisions, and by 2022, there were approximately 5,000 children forcibly separated from their parents due to the government’s policies surrounding the program.

Complaints filed with the International Criminal Court and the UN indicate most workers did not volunteer for the program, some never saw a contract or knew their destination, many had their passports confiscated by Cuban officials once they arrived at their destination, and almost all had “minders” or overseers.  According to the complaints and survivors, Cuban heads of mission in the country subjected workers to surveillance, prevented them from freely associating with locals, and imposed a strict curfew.  Cuba also confiscated between 75 and 90 percent of each worker’s salary.  As a result of the well-founded complaints and information about the exploitative nature of Cuba’s labor export program, at the end of 2023, the UN Special Rapporteur for Contemporary Forms of Slavery filed a new communication outlining the persistent concerns with the program, particularly for Cuban workers in Italy, Qatar, and Spain.

While exploitation, including forced labor, of workers remains the primary concern with the program, Cuba’s practices can also negatively impact a host country’s healthcare system.  Survivors of the program have reported being forced by the Cuban in-country mission director to falsify medical records and misrepresent critical information to justify their presence and need to local authorities.  Some individuals reported discarding medications, fabricating names, and documenting medical procedures that never occurred.  When medical workers refused to comply with the demands of the Cuban in-country mission director, they faced punishment and retaliation.  While the Cuban government promotes workers as highly skilled medical professionals and specialists, these workers often lack adequate medical training to treat complex conditions.  These practices are unethical, negligent, exploitative, and risk the lives of those they serve.

Governments should make efforts to combat human trafficking, and this includes not purchasing goods or services made or provided with forced labor.  Governments that utilize Cuba’s labor export programs despite the serious concerns with the program should at a minimum conduct frequent and unannounced labor inspections to screen these workers for trafficking indicators and employ victim-centered interviewing techniques.  These host governments should ensure all Cuban workers are subject to the same laws, regulations, and protections as for other migrant workers and that they are not brought via a negotiated agreement with the Government of Cuba that limits these protections or exempts Cuban workers from Wage Protections Systems or other tools designed to strengthen transparency.  Officials should ensure workers maintain complete control of their passports and medical certifications and can provide proof of full salary payment to bank accounts under the workers’ control.  They should scrutinize medical reports produced by these workers, offer protection for those who face retaliation and punishment for terminating their employment, and raise awareness of trafficking risks for all foreign workers, including government-affiliated Cuban workers.

  • Nothing About Us Without Us:   Human Trafficking and Persons with Disabilities

Human traffickers often take advantage of persons in vulnerable situations including individuals who lack access to services and programs or rely on the assistance of others.  Among this group of potential targets are persons with disabilities, who represent about 16 percent of the world’s population, or 1.3 billion people, according to the World Health Organization.

Of course, these 1.3 billion people are not monolithic.  Some people have a disability from birth; others experience disability later in their lifetime.  Some disabilities are life-long, and others may be temporary.  A disability can be visible, such as a physical disability, or non-apparent, such as an intellectual or psychosocial disability.  People with disabilities are of every age, race, sex and sex characteristics, sexual orientation, gender identity and expression, economic status, and nationality.

Professors Andrea Nichols and Erin Heil have noted the “heightened risk as well as heightened prevalence” of human trafficking involving persons with disabilities, although the authors acknowledged the paucity of existing research.  Even when research about persons with disabilities is conducted, it rarely addresses additional intersecting identities, such as race, ethnicity, age, gender, religion, sexual orientation, gender identity, gender expression, or migratory status, that can exacerbate marginalization.

The intersection between disability and human trafficking can be cyclical.  On the one hand, persons with disabilities are more likely to be targeted by traffickers; on the other hand, the experience of being trafficked can lead to or exacerbate existing disabilities through physical injuries or emotional trauma that in turn could heighten vulnerability.

Even with access to support, persons with disabilities face increased risk of exploitation.  A caregiver may exploit their position to victimize the person they are assisting.  Persons with disabilities who receive financial assistance may be exploited for those benefits.  As the Human Trafficking Legal Center has explained with respect to the situation in the United States:  “While persons with disabilities may be trafficked into sex or labor, many cases include one additional element:  the theft of Social Security or disability benefits.  The opportunity to steal government benefits provides an added incentive for traffickers to target persons with disabilities.”  Persons with disabilities across the globe who receive benefits face similar challenges.

In light of this situation, it is perhaps not surprising that the centerpiece of the United States’ statutory framework to combat trafficking, the Trafficking Victims Protection Act (TVPA), was promulgated in part as a reaction to the Supreme Court’s decision in United States v. Kozminski , 487 U.S. 931 (1988), a case involving two men with intellectual disabilities held in what justices referred to as “slave-like” conditions on a farm.  In the case, the Court held that the law banning “involuntary servitude” was limited to circumstances involving “the compulsion of services by the use or threatened use of physical or legal coercion.”  However, Congress subsequently passed the TVPA, which recognized that psychological coercion and threats of nonviolent coercion can be every bit as powerful as physical force in overcoming the will of targeted individuals.

In 2009, the U.S. Equal Employment Opportunity Commission brought a case involving Henry’s Turkey Service, which exploited 32 intellectually disabled men at a farm in Atalissa, Iowa.  For more than 30 years, the men endured physical and mental abuse and received virtually no pay.  The jury awarded the men what at the time was the largest-ever award in an employment-discrimination case – $240 million – although it was later reduced to $1.6 million due to a federal cap in the Americans with Disabilities Act.

Not only did the TVPA arise in part from trafficking crimes involving persons with disabilities, one of the first major trafficking prosecutions in the United States involved persons with disabilities.  In that case, dozens of immigrants with hearing disabilities, including young children, were forced to work 18-hour days as trinket vendors in New York City.  Traffickers targeted persons with disabilities who were also young migrants and did not speak English, exemplifying how disability can intersect with other forms of vulnerability.  Sadly, this form of exploitation of persons with disabilities continues to this day.

The TIP Report enhanced its coverage of the intersection of disability and trafficking, with the 2023 TIP Report referencing persons with disabilities in 65 country narratives, up from about 50 in the 2022 TIP Report.  These references also highlighted the existence or lack of specialized services for persons with disabilities who are victims of trafficking, and the particular challenges faced by persons with physical or intellectual disabilities.

The U.S. Department of State’s disability rights work is led by Special Advisor on International Disability Rights Sara Minkara.  In this appointed position, Ms. Minkara leads the comprehensive strategy to promote and protect the rights of persons with disabilities across U.S. foreign policy.  Special Advisor Minkara embodies the slogan “nothing about us without us,” which is often used by disability rights advocates to insist that persons with disabilities participate fully in policies affecting them.  The role of Special Advisor on International Disability Rights was first held by Judy Heumann, who served in the position from 2010 to 2017 and is widely regarded as the “mother of the disability rights movement.”  Sadly, Ms. Heumann passed away in March 2023, leaving behind an indelible legacy of disability advocacy in the United States and around the world.

From left:  Former Special Advisor on International Disability Rights (SAIDR) Judy Heumann, SAIDR Sara Minkara, and Special Assistant to the Special Advisor Hanah Nasri attend a celebration of the anniversary of the Americans with Disabilities Act at the official residence of the Vice President of the United States in July 2022.  Photo courtesy of Hanah Nasri. (Photo was published in State Magazine in March 2023:  https://statemag.state.gov/2023/05/0523office/ ) .

  • Key Trafficking Issues in the Western Hemisphere Region

Human trafficking manifests itself differently around the world.  In the Western Hemisphere – North, Central, and South America and the Caribbean – there are broad commonalities in trafficking trends countries face and how their governments and authorities approach the crime.  Below is an overview of shared issues in the region to illustrate the overall situation and coordinate the anti-trafficking efforts of governments and other stakeholders .  These regional issues are extrapolated from the individual narratives for the countries in the region, including the United States.

Unprecedented irregular migration in the region affects all Western Hemisphere countries.  Migrants and asylum seekers are especially vulnerable to sex trafficking and forced labor, including by large and small organized criminal groups.  Migrants who rely on migrant smugglers are at particularly high risk of exploitation as many assume debt to pay migrant smugglers.  Irregular migration may also include individuals already exploited by traffickers, as victims may be motivated to migrate and seek protection elsewhere.  While some countries enacted policies aimed at reducing migrants’ vulnerability to trafficking by providing temporary residency and access to formal employment, education, healthcare, and other services, we encourage all countries faced with irregular migration challenges to prevent trafficking and prioritize screening among migrants.

Countries across the region generally have a good understanding of and response to sex trafficking, especially in identification of women who are victims.  Governments also undertake and emphasize the importance of law enforcement and criminal justice approaches to address trafficking, even if implementation is uneven.  Many governments seek to tackle both internal and transnational human trafficking.  In broad terms, there is political will in many countries to address human trafficking, particularly sex trafficking.

Weak efforts targeting forced labor remain a concern in the Western Hemisphere.  Governments generally focus on addressing sex trafficking and have weaker, poorly enumerated procedures to prosecute labor traffickers and protect victims of forced labor.  Labor inspectorates are underfunded and understaffed and typically have limited or no authority to inspect informal sector worksites where many victims are exploited, especially along changing migration routes.  Governments’ lack of attention to labor trafficking leaves victims unprotected in multiple sectors, including agriculture , mining , logging, maritime, and service .

Traffickers also exploit many victims in forced criminality .  Organized crime groups, including gangs and illegal armed groups, exploit girls in child sex trafficking, force children into street begging, forcibly recruit or use child soldiers, and coerce and threaten young men and women to transport drugs, commit extortion, act as lookouts, or commit acts of violence, including murder.  Organized crime groups target groups of migrants unable to enter a country due to border restrictions or awaiting asylum decisions, including at the U.S.-Mexico border.  State-sponsored forced labor is also a concern, specifically Cuba’s labor export program, including its medical missions – which the Cuban government continues to profit from by subjecting workers to forced labor and exploitation.

Gaps in trafficking victim protection are another broad concern in the Western Hemisphere.  For years governments have lacked (or failed to provide the necessary) financial and human resources to screen for and identify trafficking victims and provide them trauma-informed services.  Some governments have developed policies and protocols for screening victims and referring them to care, but implementation has been inconsistent or ineffective.  In addition, governmental interagency coordination is weak, with working groups often disjointed and disempowered, which is particularly detrimental to the cross-sectoral collaboration needed for victim protection efforts.  These problems are particularly notable among migrants, whom governments rarely screen for trafficking indicators.

Furthermore, governments make weak screening and identification efforts even with underserved populations and marginalized groups recognized as at high risk to trafficking, including Afro-descendant, Indigenous, and LGBTQI+ persons, as well as members of other ethnic and linguistic minorities, migrants, refugees, and displaced persons.  These populations also frequently experience discrimination from authorities, often making them fearful to report crimes or access care and justice.  Finally, there are insufficient trafficking-specific services for victims, particularly for men and boys, in most countries across the region.  Governments refer identified trafficking victims to support systems designed to serve other populations, such as migrants, individuals experiencing homelessness, or victims of gender-based violence, which do not meet the specific needs of trafficking victims.  Similarly, access to justice and services is concentrated in large urban areas, while the most vulnerable individuals frequently live in rural areas with limited government presence.  Lack of victim-centered and trauma-informed services can hinder victim identification, prevent healing, increase risk of re-trafficking, and fuel impunity by making survivors less likely to participate in the case against their traffickers.

Criminal justice responses and definitions of trafficking are concerning across the region.  Many governments have weaknesses in their legal systems and uneven judicial application of trafficking laws, including levying fines in lieu of imprisonment for trafficking crimes, imposing penalties not commensurate with those for other crimes, and failing to criminalize all forms of child sex trafficking.  Judges, in particular, may lack adequate training in applying trafficking laws and coercive methods traffickers use, which impacts their decisions and sentences.  Impunity for trafficking crimes fosters misperceptions about trafficking among both policymakers and the public.  Inadequate law enforcement efforts and insufficient capacity-building for law enforcement and other first responders hinders or impacts efforts in low-capacity countries , especially in the Caribbean.  Governments with limited resources often do not recognize or implement low-cost/high-impact anti-trafficking policies.  Official complicity within law enforcement, the prison system, and local government facilitates trafficking crimes across some governments, but criminal prosecution of complicit officials lags behind the already low number of convictions of other traffickers.  Child sex trafficking and extraterritorial commercial child sexual exploitation and abuse are also pervasive concerns, particularly due to the increased use of social media and online platforms to recruit victims.  Many officials conflate human trafficking with other crimes, including migrant smuggling, child labor, sexual violence against children, illegal commercial sex, and illegal adoption.  Because of this confusion, governments may misidentify trafficking victims, fail to give them adequate support, and therefore underreport trafficking crimes.  These problems lead to inadequate data collection and reporting on human trafficking and, therefore, an incomplete understanding of the extent of the crime in the hemisphere.

  • A Framework for Balancing Prosecution, Prevention, and Victim Protection Priorities in Criminal Justice Systems

Holding human traffickers accountable is an essential component of the Palermo Protocol’s “3P” paradigm of prosecuting traffickers, protecting victims, and preventing the crime.   Prosecutions make powerful statements that human trafficking will not be tolerated, and perpetrators will be held accountable, and because it is important to recognize that prosecution, protection, and prevention efforts are all inextricably intertwined.   Victims are better able to assist in investigations and prosecutions when they have access to robust protections, and successful prosecutions protect individual victims from revictimization in addition to preventing the convicted trafficker from exploiting others.

Supporting victims throughout the criminal justice process is critical.   Cases often move slowly, leaving victims anxious about the uncertainty of the outcome, fearful of retaliation, re-traumatized by having to recount traumatic events, frustrated by proceedings that can disrupt their lives, and embarrassed, ashamed, or ostracized when information about their victimization becomes public.   These feelings of anxiety, uncertainty, trauma, frustration, and fear can be further intensified by the distrust of authorities that traffickers often instill and manipulate to compel victims’ silence and their compliance with the traffickers’ commands.   Victims often experience conflicting pressures from authorities encouraging them to cooperate, traffickers seeking to silence them, and their own efforts to put traumatic events behind them.   For some survivors, the opportunity to speak out, be believed, and play an active role in bringing traffickers to justice can be empowering and vindicating.   Yet for many, the process can be harrowing, especially when they do not receive sufficient services and support.

The difficulties victims often experience during investigations and prosecutions can further intensify the challenges authorities face when seeking to hold perpetrators accountable, protect their communities, and prevent traffickers from harming others.   In striving to bring traffickers to justice without unduly burdening, re-traumatizing, or endangering victims, prosecutors continually balance the interests of justice, public safety, and protection of the community with the rights and interests of individual victims.   Successful strategies for navigating these challenges will inevitably vary to some extent according to the relevant laws and criminal justice systems across various jurisdictions but the promising practices highlighted below can aid in effectively balancing these complex considerations in a wide range of contexts.   The end goal is to enhance support for victims and decrease the burdens they experience during the criminal justice process regardless of whether they are testifying — while also strengthening investigations and prosecutions to increase accountability for traffickers.

Vigorous Victim Protections at All Stages of the Criminal Justice Process

The best way for authorities to support human trafficking survivors is to ensure the provision and continuity of comprehensive services at all stages of the criminal justice process, including in coordination with civil society organizations who specialize in victim services.   Children survivors require specialized care and interventions.   Robust victim protections, including comprehensive victim-centered, trauma-informed services, are essential to support victims in rebuilding their lives, providing the security and stability they need to safely participate in the criminal justice process, and enabling them to recall and recount their experience.   Such services should include access to identity documents, mental health and medical services, housing, and other forms of relief to support physical and mental healing.   In addition, survivors should have access to legal support and services, ideally through an independent legal advocate.   This support should be tailored to assist the survivor with a range of legal needs, whether related to navigating the investigation and prosecution of the criminal case against the trafficker, to immigration relief, or other legal matters.

Investigators, prosecutors, and victim service providers should collaborate closely to ensure that the victim is stabilized and supported before expecting meaningful participation in the criminal justice process.   Trauma can impede a victim’s ability to recall and recount relevant events, so investigators and prosecutors should develop advanced expertise in victim-centered, trauma-informed, culturally appropriate methods for stabilizing survivors, building rapport, and conducting effective interviews.   Effective interviewing may entail consistent use of professional interpreters to ensure clarity of communication and often benefits from the use of specialized techniques that incorporate the expertise of survivor leaders.   These practices can make the victim’s participation in the process less burdensome and traumatic.   They can also strengthen prosecutions by eliciting more accurate statements, minimizing discrepancies that could later be used to attack the victim’s credibility, and enabling the victim to provide more detailed information that could lead to other sources of evidence.

Protection and services for trafficking victims should not be conditioned on whether the trafficker is charged or convicted.   In cases where a foreign victim chooses to return to their home country, relocation assistance should be provided and authorities should proceed with prosecutions involving repatriated victims when possible, by having them present evidence virtually where authorized by law or by funding their return travel for court proceedings as necessary.   Access to comprehensive support is not only in the best interest of survivors- it also increases the likelihood they will feel sufficiently safe and empowered to assist in the investigation and prosecution.   Whether survivors testify against the trafficker or provide more limited assistance to law enforcement, support for their long-term well-being should be a priority even after the case is closed.

Developing Evidence to Decrease Reliance on Victim Testimony

Another best practice in prosecuting trafficking cases is the use of strategic investigative processes to develop evidence that supports the statements or testimony of trafficking survivors.   In human trafficking prosecutions, every piece of evidence counts because each piece of corroborating evidence is important to reduce reliance on victim testimony, preventing undue credibility attacks, and to increase the likelihood of conviction.

All human trafficking victims who provide statements, declarations, or testimony are inevitably subjected to credibility challenges, whether by jurists in inquisitorial systems that decide whether the victim’s statements are sufficiently reliable or by the defense in adversarial systems.   Victims’ credibility is often scrutinized based on issues such as delays in reporting their victimization, trauma-related inconsistencies in recalling and recounting certain details, or involvement in unlawful acts related to their victimization.   Corroborating evidence can be essential to countering such credibility attacks, increasing the likelihood of the victim’s statements or testimony being believed, and leading to higher rates of convictions.   Investigators and prosecutors should engage in early and continuous collaboration to assess ways to pursue other sources of evidence beyond victim testimony and to corroborate available statements and evidence through sources such as electronic records, physical evidence, and other potential witnesses.

In some cases, other admissible evidence uncovered during a thorough investigation may minimize the need for victim testimony and can become essential to enabling a prosecution to proceed even if the victim is not able to participate in the trial.   Even evidence that provides only limited circumstantial corroboration of one small aspect of a trafficker’s conduct can, when combined with other evidence, provide significant substantiation of a survivor’s account.   Investigators and prosecutors should clearly communicate to survivors that they are not “responsible” for the successful investigation and prosecution, that services and protections are not dependent on the outcome of the criminal case, and that authorities are responsible for gathering relevant evidence from all available sources.   Such evidence can also significantly reduce the burdens felt by the victim and the risks of re-traumatization associated with participating as a witness.

Victim-Centered, Trauma-Informed Charging and Prosecution Practices

One of a prosecutor’s most serious responsibilities is to utilize all available avenues to protect the victim and prevent witness intimidation efforts that could compromise both the victim’s sense of safety and the integrity of the investigation.   Such avenues include seeking court orders, including restraining orders, orders of protection, and no-contact orders to prohibit the defendant from attempting to contact the victim either directly or indirectly.   They also include working with law enforcement and victim advocates to prepare a safety plan and document any attempted contact.   Prosecutors should encourage survivors to seek help from a trusted point of contact with the police or other authorities and to immediately disclose to the prosecutor or advocate any attempt by the traffickers to contact them.   Documented attempts to contact or intimidate the victim should be used in appropriate instances to bring additional obstruction-of-justice or witness tampering charges and may be relevant to explain a victim’s reluctance to cooperate as a witness or recant earlier statements.   Proof of the trafficker’s efforts to contact the victim may also allow the prosecutor to introduce otherwise inadmissible evidence.

Even if the survivor is able and willing to testify, the prosecutor should introduce corroborating evidence to bolster and support their testimony, which is especially important when a survivor’s trauma has caused inconsistency in their statements or memory.   Prosecutors may also consider using expert testimony in appropriate instances to explain the impacts of trauma on memory and recall.   Admissible evidence may include the survivor’s medical records, testimony from first responders or other witnesses to relevant incidents, certain statements made by the accused, electronic messages, physical evidence recovered from relevant locations, and video recordings.   Additional evidence gathered using well-designed and implemented strategic investigative processes can in some instances serve, when possible, as a substitute for the victim’s critical testimony, either completely or on select issues, if the victim becomes unavailable or has difficulty testifying effectively.

Unfortunately, despite all efforts to develop other evidence, some cases of the underlying trafficking offenses cannot proceed without the testimony of the victim.   In those instances, certain practices can be used to pursue prosecutions and accountability while minimizing undue burdens and adverse impacts on survivors.   Prosecutors can strategically focus charges on the most readily provable aspects of the criminal conduct such as assaults, threats, financial crimes, possession of illicit images, or witness tampering, which may be less reliant on victim testimony but may still provide significant opportunities to hold offenders accountable.   Prosecutors can also seek to resolve cases through guilty pleas in appropriate instances to secure substantial justice without the need for victim testimony at trial.

When a victim does need to testify, prosecutors should file all applicable motions to limit the scope of their testimony to relevant facts and preclude inappropriate cross-examination about the victim’s prior bad acts or sexual history.   When allowed by law, prosecutors should consider seeking the court’s permission to present the victim’s testimony virtually or in any other manner that preserves the defendant’s right to confront the accuser while physically separating the victim from the defendant.   Victim services and security should be provided throughout all stages of trial preparation, trial, and sentencing.

Human trafficking survivors with lived experience are uniquely positioned to provide insight, guidance, and expertise on establishing appropriate support systems, strategic investigative processes, and prosecutorial practices that allow victims to be heard and supported at all stages of investigations and prosecutions.   Incorporating survivor-informed expertise is essential to providing the security, stability, and support survivors need to participate safely and effectively as witnesses, while reducing the burdens and risks of re-traumatization often associated with the criminal justice process and strengthening efforts to hold traffickers accountable.

  • The Intersection of Forced Marriage and Human Trafficking

The question of whether forced marriage constitutes a human trafficking crime is complex, and the answer can vary depending on the circumstances of the forced marriage and the applicable national laws.

Governments around the world have taken different approaches to the issue, both in terms of the laws they have enacted and of the way those laws are implemented in practice.   While the governing international law on trafficking in persons, the UN TIP Protocol, allows for flexibility in how State Parties criminalize human trafficking under domestic legislation, establishing exploitative intent is critical to considering whether the conduct constitutes trafficking in persons.

What is forced marriage?

The 2022 update to the U.S. Strategy to Prevent and Respond to Gender-Based Violence Globally defines forced marriage as a marriage at any age that occurs without the free and full consent of both parties, including anyone under the age of 18 who is not able to give full consent.   Forced marriage may occur when family members or others use physical or emotional abuse, threats, fraud, or deception to obtain an individual’s agreement.   In such cases, an individual cannot be considered to have consented to the marriage.   The terms “early marriage” and “child marriage” are often used interchangeably to refer to any marriage in which at least one of the parties has not attained the age of 18.   There is overwhelming evidence that child, early, and forced marriages can increase individuals’ vulnerability to future exploitation and abuse – with long-term consequences for their health, wellbeing, safety, and opportunities.

Is Forced Marriage a Form of Trafficking under International Law?

Article 3 of the UN TIP Protocol defines “trafficking in persons” to require three essential elements—an act, conducted using one or more means, for an exploitative purpose.   Article 3 does not list forced marriage explicitly as a form of exploitation; instead, it provides that “exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs.”   Accordingly, when a forced marriage involves any of the acts, means, and purposes of exploitation listed in Article 3, it would be considered trafficking under the UN TIP Protocol.   For example, forced marriages that also involve forced labor or services, or slavery or practices similar to slavery would also be trafficking in persons if the relevant acts and means are present.   However, the non-exhaustive list of forms of exploitation in Article 3 allows State Parties to decide to expand the list of forms of exploitation within their own domestic definition of trafficking in line with the purpose and scope.

While the UN TIP Protocol does not explicitly include forced marriage within the definition of trafficking, many stakeholders argue that if all the elements of trafficking are present (i.e., there is an act, a prohibited means, done for the purpose of exploiting another person), it should not matter that the exploitation takes the form of a forced marriage.   These stakeholders point to the identical practices used by unscrupulous recruiters who are paid by business owners or prospective husbands to deceive and obtain the consent of individuals to marry “loving wealthy husbands” or accept “lucrative job offers,” in both instances only to leave victims trapped and exploited.

Countries that have chosen to include forced marriage within their domestic definitions of trafficking, either explicitly or implicitly, have taken three common approaches:

Forced Marriage Included as a Form of Exploitation

By leaving the list of forms of exploitation under Article 3 open-ended, the UN TIP Protocol allows State Parties to choose to expand the list of forms of exploitation included under domestic anti-trafficking laws.   As such, some countries have chosen to include forced marriage as an exploitative purpose under their respective anti-trafficking laws.   Several countries have taken this approach, including, but not limited to: Argentina, Australia, Botswana, Cambodia, Chad, Costa Rica, Croatia, Ecuador, El Salvador, Haiti, Kenya, Lithuania, Nicaragua, North Macedonia, Seychelles, and Uganda.

“Practices Similar to Slavery” Interpreted to Include Some Forms of Forced Marriage

Other countries interpret the inclusion of “practices similar to slavery” within Article 3 of the UN TIP Protocol to include certain forms of forced marriage.   “Practices similar to slavery” is defined in the Supplementary Convention on the Abolition of Slavery, the Slave Trade, and Institutions and Practices Similar to Slavery.   Under Article 1(c) of this convention, “practices similar to slavery” refers to, inter alia, “Any institution or practice whereby: (i) A woman, without the right to refuse, is promised or given in marriage on payment of a consideration in money or in kind to her parents, guardian, family or any other person or group; or (ii) The husband of a woman, his family, or his clan, has the right to transfer her to another person for value received or otherwise; or (iii) A woman on the death of her husband is liable to be inherited by another person …”   For countries that use this definition of “practices similar to slavery” to interpret the scope of the definition of trafficking in persons under the UN TIP Protocol, some, but not all, forms of forced marriage could constitute trafficking in persons.

Forced Marriage and Trafficking in Persons as Distinct Crimes .

It is also worth mentioning that there are many countries that choose to address forced marriage and trafficking in persons as separate offenses.   In its 2020 Issue Paper “Interlinkages Between Trafficking in Persons and Marriage,” the United Nations Office on Drugs and Crime (UNODC) acknowledges the viability of these different approaches and explains that there is “no one-size-fits-all approach to most effectively counter cases involving interlinkages between trafficking in persons and marriage.”

Establishing Exploitative Intent is Critical in All Approaches

At the heart of the question of whether a forced marriage constitutes a human trafficking crime is the question of whether the intention was to exploit a person or persons through the marriage.   Recently, the European Parliament and the Council of the European Union recognized the gravity of and increasing linkages between forced marriages and human trafficking. They formally adopted a directive noting that the exploitation of forced marriages “fall[s] within the scope of offenses concerning trafficking in human beings…to the extent that all the criteria constituting those offenses are fulfilled.”

While States that choose explicitly to include forced marriage within their definition of exploitation, or implicitly, through the inclusion of “practices similar to slavery,” consider “forced marriage as inherently exploitative,” such an interpretation is neither required nor shared by all States.   As UNODC explains,

…cultural and national contexts are relevant in determining exploitation, especially in relation to forced and servile marriage.   Cultural and other context-specific factors can play a role in shaping perception of what constitutes exploitative conduct for the purposes of establishing that trafficking has occurred.

Marriages generally involve domestic work and sexual relations between spouses, neither of which is generally understood to constitute abuse or exploitation.   However, there are circumstances in which individuals may be exploited in connection with each of these under the guise of marital obligations.   Taking into consideration the cultural and national contexts in which marriages transpire is a complex but necessary task when determining whether all three elements of a human trafficking offense are present in a case involving forced marriage.

While it is understood forced marriage is inherently harmful, rooted in gender inequality, and can often dramatically increase the risks of individuals to trafficking in persons, gender-based violence (GBV), and other abuses or crimes, it is important to acknowledge there may be circumstances in which a forced marriage has occurred, but the offense of human trafficking has not, because the purpose of the marriage was not to exploit another individual.   For example, in some communities, even an untruthful allegation of sexual indiscretion or promiscuity can irreparably damage a girl’s prospects of marriage or place her in physical danger.  Parents in these communities may attempt to protect their daughters by marrying them at a young age to avoid such allegations and safeguard their reputations.  Similarly, families who live in refugee camps or other unstable situations where there is high prevalence of multiple forms of violence, including GVB, may view marriage as a protective mechanism that will prevent their daughters from being victims of physical or sexual violence or offer them greater economic security.   In these instances, such marriages commonly occur without an individual giving their full, free, and informed agreement to marry.   By definition, such an arrangement would constitute a forced marriage and depending on the country, potentially a violation of domestic criminal laws.   However, if no one involved in arranging the marriage (not the spouse, parents, matchmaker, etc.) is participating for the purpose of exploiting the individual , then the necessary elements of trafficking in persons are not met.   Other crimes or human rights abuses may have occurred and should be addressed, but the specific crime of human trafficking has not occurred because the marriage was not for the purpose of exploitation.   To the contrary, taking into account the relevant cultural and social norms, these actors may believe they are acting in the best interest of the individual.   As in all criminal cases, the knowledge and intent of the individual matters and therefore, in the case of forced marriages as a potential trafficking crime, one must consider if an individual intended to exploit someone, or whether they intended, even misguidedly and mistakenly, to do what was believed to be in the individual’s best interest.   These complicated dynamics must be determined in other trafficking contexts as well.

Therefore, when allegations of forced marriage are presented, they must be evaluated on a case-by-case basis to determine whether they constitute trafficking in persons.   Such an assessment neither legitimizes forced marriage nor detracts from serious concerns around such practices.   Rather, it simply ensures the appropriate criminal prosecution, protection, and prevention responses are utilized to address the conduct in question because, as UNODC explains, “….qualifying a particular type of conduct as trafficking in persons has extensive consequences for both the alleged perpetrators and victims of the crime.”

* NOTE:   U.S. law does not explicitly recognize forced marriage as a “severe form of trafficking in persons” or reference it in criminal trafficking laws.   Therefore, forced marriage, per se, is not automatically considered a form of trafficking in persons under U.S. law.   The facts and circumstances of the forced marriage must be considered to determine whether the conduct falls under a relevant definition or legal provision.   Generally, if the person forced to marry is also compelled to work or to engage in commercial sex, then the forced marriage would likely fall within the definition of trafficking in persons and be a crime under U.S. law.   Because the definition of “severe forms of trafficking in persons” established under the Trafficking Victims Protection Act governs the Department’s minimum standard assessments for the purposes of the TIP Report, the Department accordingly includes governments’ efforts to combat forced marriage if there is credible evidence that those efforts address forced marriage in which the objective of the marriage was to exploit another person for labor or services or commercial sex.

An Example of When a Forced Marriage Involved Human Trafficking:   United States of America v. Zahida Aman, et al.

In United States of America v. Zahida Aman, et al., the United States successfully prosecuted and convicted three individuals for trafficking crimes relating to a forced marriage.   On January 24, 2023, the traffickers were sentenced to five, ten, and 12 years of imprisonment, respectively, and ordered to pay restitution to the victim.   The case serves as an example of how forced marriage and human trafficking can intersect and result in complex and devastating exploitation of vulnerable individuals, as abuse often goes undetected for long periods of time due to its hidden nature within the confines of familial relationships.

A federal jury sitting in Richmond, Virginia, found defendants Zahida Aman, Mohammad Nauman Chaudhri, and Mohammad Rehan Chaudhri guilty of conspiracy to commit forced labor for compelling the domestic labor of a Pakistani woman for 12 years.   The jury further found defendant Aman guilty of forced labor and document servitude, and defendant Rehan Chaudhri guilty of forced labor.

According to the evidence presented in court, defendant Zahida Aman arranged for her son’s marriage to the victim in 2001.   The victim moved to the United States and lived in a house in Midlothian, Virginia, with her husband and the three defendants (the husband’s mother and his two brothers).   The defendants compelled the victim to serve the family as a domestic servant, using physical and verbal abuse, restricting communication with her family in Pakistan, confiscating her immigration documentation and money, and eventually threatening to separate her from her children by deporting her to Pakistan.

The defendants slapped, kicked, and pushed the victim, even beat her with wooden boards, and on one occasion hog-tied her hands and feet and dragged her down the stairs in front of her children.   Even after the victim’s husband moved away, the defendants kept the victim in their Virginia home, often forcing her to perform increasingly laborious tasks… 

The evidence further showed that the defendants required the victim to work every day, beginning early each morning.   They restricted her food, forbade her from learning to drive or speaking to anyone except the defendants’ family members and prohibited her from calling her family in Pakistan.

Press Release, U.S. Department of Justice

  • 2024 TIP REPORT HEROES

This year marks a major milestone—the 20th anniversary of the TIP Report Heroes awards program.   Each year, the Department of State honors individuals around the world who have devoted their lives to the fight against human trafficking.   These individuals include NGO workers, lawmakers, government officials, survivors of human trafficking, and concerned citizens.   They are recognized for their tireless efforts—despite some working in challenging environments where human trafficking concerns remain pervasive and facing resistance, opposition, or threats to their lives—to protect victims, punish offenders, and mitigate the underlying factors that cause vulnerabilities traffickers often target.

For more information about current and past TIP Report Heroes, please visit the TIP Report Heroes Global Network at www.tipheroes.org .

Al Amin Noyon Manager BRAC Migration Centre

Md. Al-Amin, or Noyon, is a welcoming first face to trafficking survivors and migrants as they return to Bangladesh.  As a fellow trafficking survivor, Noyon is uniquely qualified and motivated to help them rebuild their lives. In his capacity as manager of the BRAC Migration Welfare Centre onsite at the Dhaka airport, Noyon has supported more than 34,000 Bangladeshi trafficking survivors and migrants over the last 15 years.

Born to a family of modest means, Noyon’s dream of a better life turned into a nightmare when he was exploited in trafficking in Malaysia in 2007, beaten, tortured, and held captive in the jungle.  But as the 41-year-old now shares, that is not how his story ends.  His motivation to support fellow survivors has long motivated him to serve as a member of ANIRBAN (‘the flame that will not fade ‘ ), a trafficking support platform made up of survivors who raise awareness about human trafficking and advocate for survivors and their rights.

Noyon believes education is one of the best ways to insulate Bangladesh’s next generation from the perils of human trafficking.  He assists with safe migration campaigns at schools across Bangladesh and has supported thousands of students whose families are migrants or trafficking survivors secure academic scholarships.

Known by anti-trafficking stakeholders in the Bangladesh government, multilateral organizations, and likeminded partners, Noyon steadfastly supports others despite very real risks to his own safety.

Marcela Martinez Activist/Lawyer

Ms. Martinez is an accomplished Bolivian lawyer from La Paz and a leading anti-trafficking activist, who has demonstrably changed the direction of Bolivian and regional efforts to combat trafficking in persons, providing hope for families affected by human trafficking in Bolivia.

In 2017, Ms. Martinez formed the Social Responsibility Area of her law firm, from which the #RedAlertTempranaZar 🦋 hashtag operates.  This hashtag is modeled after the Amber Alert system in the United States to help activate searches for victims in Bolivia.  They also provide training, talks, workshops, and prevention webinars to schools, universities, neighborhood associations, and other civil society organizations.  To date, more than 18,000 volunteers participate in the network and have helped authorities locate more than 150 victims.

Ms. Martinez’s work has been instrumental in the prosecution of traffickers, protection of survivors, and prevention of victims.  She helped draft and lobbied for the passage of the first comprehensive Bolivian national law that gives law enforcement and prosecutors new tools and resources to combat trafficking in persons.  She also created the National Trafficking in Persons Council to coordinate all Bolivian government efforts to fight human trafficking.

She was part of the NinaSonko Heart of Fire Women’s Circle, which provides support and holistic and business coaching to survivors of trafficking and violence and supports social reintegration.  She has also served as a trainer through UNODC, training judges, prosecutors, and police officers on victim care at the national level.  Through her tireless efforts, Ms. Martinez has reduced human trafficking in Bolivia.

Maria Werlau Founder/Executive Director Free Society Project

Maria Werlau is co-founder and Executive Director of Free Society Project, also known as Cuba Archive, a non-profit think tank that defends human rights through information.  She began in 2009 researching, documenting, and denouncing exploitation and forced labor in Cuba’s labor export program and advocating for its victims and survivors.  In 2010, she published her first academic work on the issue and authored an opinion piece in The Wall Street Journal denouncing the labor export program as a trafficking scheme benefiting the Cuban government.  At the time, Cuba’s “internationalism” was mostly known from the slanted narrative of altruistic solidarity.

Since then, Maria has interviewed dozens of Cuban workers, mostly doctors coerced to work across the globe.  Through her work at Cuba Archive, she has exposed the dark aspects of Cuba’s medical missions, emphasizing the abuses faced by the workers: violence, sexual harassment, family separation, exploitation, forced labor, wage confiscation, restriction of movement, passport retention, repression, forced exile, psychological trauma, loss of life, and more.  She has also documented and exposed the labor export program’s lesser-known impact on the public health systems of Cuba and host countries, as well as its economic, political, and geostrategic value to the Cuban regime.

Maria has authored numerous works on Cuba in English and Spanish, including on healthcare, and provided expert testimony on Cuban labor trafficking to the U.S. Congress and at the OAS and the European Parliament.

Mustafa Ridha Mustafa al-Yasiri Director – Anti-Human Trafficking Directorate Ministry of Interior

Brigadier General Mustafa Ridha Mustafa al-Yasiri has courageously worked in Iraq’s Ministry of Interior (MOI) to combat trafficking in persons throughout a career dedicated to defending Iraq’s most vulnerable.  Brigadier General Mustafa vastly improved the Government of Iraq’s efforts to combat trafficking in persons and enhanced services for women trafficking victims, only months after being appointed in March 2023 as the Director of MOI’s Anti-Human Trafficking Directorate.  With support from the Minister of Interior, Brigadier General Mustafa immediately increased government resources dedicated to fighting trafficking in persons; appointed women Trafficking in Persons officers and employees to better assist trafficking victims; and appointed new investigative officers and officials knowledgeable on trafficking in persons, victim identification, and violence against women.  Together with the Iraqi judiciary, Mustafa established a strategy to identify victims more accurately and better address sexual exploitation and other forms of trafficking.

In addition, Brigadier General Mustafa worked with hiring companies to ensure they publish and display signs detailing Iraqi workers’ rights and the MOI’s Trafficking in Persons hotline.  On a weekly basis, he visited shelters to speak with victims, compile lists of needed food and hygienic and medical supplies, and help victims make calls to their families.  He also personally accompanied trafficking victims to court to help with their hearings and legal procedures.  Every day, motivated by personal conviction, Brigadier General Mustafa is realizing a professional goal to serve and protect many of the most vulnerable citizens of Iraq.

Edith Murogo Founder/Chief Executive Officer Centre for Domestic Training and Development

Edith Murogo is a beacon of hope on the frontlines of the fight against human trafficking and labor exploitation.  When Edith started training domestic workers more than two decades ago, she met victims of human trafficking and gender-based violence.  This experience prompted her to pioneer initiatives that transformed anti-trafficking efforts in Kenya.

After establishing the Centre for Domestic Training and Development (CDTD) in 2001, Edith became a leading advocate for domestic workers’ rights and lobbied the government for strengthened protections of migrant workers.  Edith initiated training to professionalize domestic workers and convinced the government to develop the curriculum and establish a certificate program for domestic workers seeking employment abroad.  Since opening, CDTD has assisted over 50,000 domestic workers with advocacy, skills, and knowledge to prevent them from becoming victims of trafficking.

In 2012, Edith opened the Talia Agler Girls Shelter (TAGS) – a safe house providing comprehensive assistance to girls and young women, especially for survivors of sexual and gender-based violence exploited in human trafficking. TAGS has assisted over 1,000 girls with removal from trafficking situations, recovery, and reintegration support services as well as education, mentorship, and leadership opportunities.

During the COVID-19 pandemic, Edith established Kenya’s National Shelters Network to coordinate shelter services across Kenya and ensure all survivors receive crucial protection services.  Edith is a tireless advocate working with government and civil society to strengthen anti-trafficking laws and responses.  The Department of Labor and BBC have highlighted her work in several documentaries about human trafficking.

Oumou Elkhairou Niaré Samaké Coordinator National Integrated Program for the Fight Against Drug Trafficking and Organized Crime; National Committee for the Fight Against Trafficking in Persons and Similar Practices

Oumou Elkhairou Niaré Samaké (Oumou), a well-known Malian magistrate, currently serves as the coordinator of Mali’s National Integrated Program for the Fight against Drug Trafficking and Organized Crime and as Coordinator of the National Committee for the Fight Against Trafficking in Persons and Similar Practices.  Oumou is a fierce advocate for human rights, gender-based violence, and trafficking in persons issues.  She has spearheaded Mali’s recent adoption of a new Action Plan to Combat Trafficking in Persons; championed the development of Mali’s new draft penal code to criminalize trafficking in persons; and fought to increase prosecutions over the past year of hereditary slavery cases.

In 2020 and 2021, the Trafficking in Persons Committee became relatively inactive.  However, upon her appointment in 2022, Oumou reinvigorated Mali’s anti-trafficking efforts.  First, she reestablished regular coordination meetings and published the Trafficking in Persons Committee’s overdue 2021 and 2022 annual reports.  Next, she spearheaded the development, drafting, and adoption of Mali’s new National Action Plan to Combat Trafficking in persons, launched in October 2023.  She has maintained high level standard of contacts with partners, donors, and national and international stakeholders in the fight against trafficking in persons and hereditary slavery.

Samson Inocencio Jr. Vice President International Justice Mission Philippines Program Against Online Sexual Exploitation of Children

Samson “Sam” Inocencio has dedicated over 20 years to combating trafficking in persons through his work with the International Justice Mission (IJM) Philippines.  He has contributed to 147 convictions for commercial sexual exploitation and 220 for online sexual exploitation (OSEC) crimes since 2005.  After becoming National Director of IJM in 2016, Sam assisted in the removal of 544 children from situations of commercial sexual exploitation and 1,237 children who were at risk of OSEC.

Sam led IJM’s efforts under the U.S.-Philippine Child Protection Compact (CPC) Partnership to combat OSEC crimes and advocated for a 347 percent budget increase for the Philippine National Police – Women and Children Protection Center.  As IJM’s representative to the Government of the Philippines’ Interagency Council Against Trafficking, Sam has assisted the Philippines in its efforts to combat the commercial sexual exploitation of children and OSEC related crimes, to hold offenders accountable in courts of law, and to safeguard Filipino children.

He collaborated with the Government of the Philippines in 2016 to develop a “roadmap to Tier 1” in the U.S. Department of State Trafficking in Persons Report.  The Philippines has been ranked Tier 1 for eight years due to the merits of its efforts.  Sam’s leadership and dedicated service have strengthened the government and civil society’s response to trafficking and protected thousands, especially children, from exploitation.

Marijana Savić Founder/Director Atina

Marijana Savić, the founder and director of NGO Atina, is an activist dedicated to advancing women’s and girls’ rights.  For over two decades, she has provided vital support and recovery programs for survivors of trafficking and gender-based violence in Serbia.  Her efforts have led to important progress in policy reform to combat human trafficking and support women and girls, who were victims of commercial sexual exploitation.

Under Marijana’s guidance, Atina has become a pivotal organization in Serbia’s anti-trafficking sector.  Marijana also actively contributes by helping integrates survivor experiences into law and human rights policies, in Serbia and abroad.  Her commitment extends to economic empowerment through the social enterprise Bagel Bejgl, which she founded in 2015.  This initiative – which provides employment to trafficking survivors – supports Atina’s sustainability by directing its profits to anti-trafficking programming.

Marijana works with international bodies, including the Council of Europe, as an expert in combating trafficking, especially labor exploitation.  An alumnus of the Human Rights Advocates Program at Columbia University, Marijana is also involved in global advocacy as a member of the Global Fund for Children’s board, Canada’s Equality Fund Investment Advisory Council, and the UN Voluntary Trust Fund for Victims of Human Trafficking board.

Marijana’s relentless activism and leadership have earned widespread acclaim and numerous awards for Atina, highlighting her role in shaping a safer, more equitable society for women and girls across Serbia and globally. Her work exemplifies a profound commitment to human rights and the empowerment of the most vulnerable groups.

Rosa Cendón Advisor – Human Trafficking and Gender-based Violence Catalonia Regional Ministry for Equality and Feminism

Rosa Cendón has devoted her life to assisting victims, raising awareness, and combating human trafficking in Spain.

As a social worker and educator based in Barcelona, Rosa has led advocacy and institutional relations for SICARcat, the largest anti-trafficking NGO in the Catalonia region, for 20 years.  SICARcat offers assistance to women and children survivors of trafficking by providing them with shelter and legal, psychological, medical, and social support.  Since 2022, Rosa has served as an expert advisor for combating human trafficking and gender-based violence at the Catalonia regional Ministry of Equality and Feminism.  She continues to promote change by raising awareness of human trafficking and designing public policy.

Rosa is at the forefront of anti-trafficking efforts in Catalonia.  Her victim-centered approach has influenced regional and national anti-trafficking and victim protection policies.  She contributed to designing the regional Catalonian and Barcelona city protocols for victim protection.  Under her leadership, SICARcat developed tools for the detection and intervention of human trafficking cases working closely with law enforcement agencies.  She regularly conducts specialized training for key actors.

During the height of the European migration crisis, Rosa helped found the ASIL.CAT network of human rights NGOs that coordinated shelter, protection, and services for the influx of refugees.  She worked to ensure that anti-trafficking efforts were included in the asylum reception system.  As a result of Russia’s invasion of Ukraine, Spain has received over 200,000 Ukrainian refugees and Rosa has been at the forefront in providing support to the refugees arriving to Barcelona.

Letitia Pinas Inspector of Police – Head of the Trafficking in Persons Unit Suriname Police Force

Inspector Letitia Pinas launched her career with the Suriname Police Force in 1998.  After serving in the Youth Affairs Department and the Public Relations Department, she was assigned the role of Acting Head of the 14-person Trafficking in Persons Unit in November 2020, to determine its continued usefulness.  Inspector Pinas overhauled the underperforming unit by drafting a strategic plan that improved the unit’s ability to investigate suspects and identify and serve victims, its presence in and outreach to the community, and the public’s trust in it.

With no NGOs working on human trafficking, Inspector Pinas assumed a disproportionate burden not only to investigate cases properly and effectively but also ensured efforts continued in the areas of protection and prevention, including expanded awareness.  Despite the government facing a multi-year financial crisis, she successfully lobbied for funds from the police to establish an emergency shelter within her office to house victims in the initial stages of an investigation.  She closely collaborated with the Prosecutors’ Office for funding to create a long-term shelter for both male and female victims.  Through improved collaboration with the Maritime Police and the Military Police, the Trafficking in Persons Unit actively participates in inspections of incoming vessels, while also checking for potential victims amongst incoming travelers at the airport.  These efforts have led to increased numbers of identified victims, including many who have trusted the police enough to self-report.  Her collaboration with senior police officials resulted in the development of a website that raises awareness on human trafficking and provides society with a tool to anonymously report suspected cases of trafficking.

  • Child Soldiers Prevention Act List

Section 402 of the Child Soldiers Prevention Act, as amended (CSPA) requires publication in the annual TIP Report of a list of foreign governments identified during the previous year as having governmental armed forces, police, or other security forces, or government-supported armed groups that recruit or use child soldiers, as defined in the CSPA.  These determinations cover the reporting period beginning April 1, 2023 and ending March 31, 2024.

For the purpose of the CSPA, and generally consistent with the provisions of the Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict, the term “child soldier” means:

  •  any person under 18 years of age who takes a direct part in hostilities as a member of governmental armed forces, police, or other security forces;
  • any person under 18 years of age who has been compulsorily recruited into governmental armed forces, police, or other security forces;
  • any person under 15 years of age who has been voluntarily recruited into governmental armed forces, police, or other security forces; or
  • any person under 18 years of age who has been recruited or used in hostilities by armed forces distinct from the armed forces of a state.

The term “child soldier” includes any person described in clauses (ii), (iii), or (iv) who is serving in any capacity, including in a support role, such as a “cook, porter, messenger, medic, guard, or sex slave.”

Governments identified on the list are subject to restrictions, in the following fiscal year, on certain security assistance and commercial licensing of military equipment.  The CSPA prohibits assistance to governments that are identified in the list under the following authorities: International Military Education and Training, Foreign Military Financing, Excess Defense Articles, and Peacekeeping Operations, with exceptions for some programs undertaken pursuant to the Peacekeeping Operations authority.  The CSPA also prohibits the issuance of licenses for direct commercial sales of military equipment to such governments. Beginning October 1, 2024, and effective throughout Fiscal Year 2025, these restrictions will apply to the listed countries, absent a presidential waiver, applicable exception, or reinstatement of assistance pursuant to the terms of the CSPA.  The determination to include a government in the CSPA list is informed by a range of sources, including first-hand observation by U.S. government personnel and research and credible reporting from various UN entities, international organizations, local and international NGOs, and international and domestic media outlets.

The 2024 CSPA List includes governments of the following countries: Please note that 2024 Child Soldiers Prevention Act-related determinations were not final at the time of releasing the 2024 TIP Report. This section will be updated as soon as possible.

  • When the Government is the Trafficker: State-Sponsored Trafficking in Persons

While the TVPA Minimum Standards for the Elimination of Trafficking In Persons and the UN TIP Protocol call on governments proactively to address trafficking crimes, some governments are part of the problem, directly compelling their citizens or other individuals into sex trafficking or forced labor.   Some governments exploit individuals in forced labor in local or national public works projects, military operations, economically important sectors, as part of government-funded projects or missions abroad, or in sexual slavery on government compounds.   Governments extract this work or service by threatening the withdrawal of public benefits; withholding salaries; intentionally failing to adhere to limits on national service; manipulating the lack of legal status of stateless individuals and other minority groups; threatening to punish family members; or conditioning services, food, or freedom of movement on labor or sex.

In 2019, Congress amended the TVPA to acknowledge that governments can also act as traffickers, referring specifically to a “government policy or pattern” of human trafficking; human trafficking in government-funded programs; forced labor (in government-affiliated medical services, agriculture, forestry, mining, construction, or other sectors); sexual slavery in government camps, compounds, or outposts; or employing or recruiting child soldiers.   While the TVPA already directs the Secretary to consider the extent to which “officials or employees of the government have participated in, facilitated, condoned, or were otherwise complicit in” trafficking when determining whether the government is making significant efforts to meet the minimum standards, this section directly links a government’s “policy or pattern” of trafficking to a Tier 3 ranking.

The 2024 TIP Report includes the following 13 countries with a documented “policy or pattern” of human trafficking, trafficking in government-funded programs, forced labor in government-affiliated medical services or other sectors, sexual slavery in government camps, or the employment or recruitment of child soldiers:    

  • Afghanistan*
  • China, People’s Republic of
  • Korea, Democratic People’s Republic of
  • South Sudan
  • Turkmenistan

* The TIP Report describes the state of human trafficking within a country and with respect to Afghanistan, assesses the actions of Afghan ministries, as well as the Taliban, without implying recognition of the Taliban or another entity as the government of Afghanistan.

  • Methodology

The Department of State prepared this report using information from U.S. embassies, government officials, nongovernmental and international organizations, published reports, news articles, academic studies, consultations with authorities and organizations in every region of the world, and information submitted to [email protected] .   This email address provides a means by which organizations and individuals can share information with the Department of State throughout the year on government progress in addressing human trafficking.

U.S. diplomatic posts and domestic agencies reported on the human trafficking situation and governmental action to fight trafficking based on thorough research that included meetings with a wide variety of government officials, local and international NGO representatives, officials of international organizations, journalists, academics, and survivors.   U.S. missions overseas are dedicated to covering human trafficking issues year-round.   The 2024 Trafficking in Persons Report covers government efforts undertaken from April 1, 2023 through March 31, 2024, to the extent concurrent reporting data is available.

Tier Placement

The Department places each country in this report onto one of four categories.   This placement is based not on the size of a country’s problem but on the extent of government efforts to meet the Trafficking Victims Protection Act’s (TVPA) minimum standards for the elimination of human trafficking (see page XX), which are generally consistent with the Palermo Protocol.

While Tier 1 is the highest ranking, it does not mean that a country has no human trafficking problem or that it is doing enough to address the crime.   Rather, a Tier 1 ranking indicates that a government has made efforts to address the problem that meet the TVPA’s minimum standards.   To maintain a Tier 1 ranking, governments need to demonstrate appreciable progress each year in combating trafficking.   Tier 1 represents a responsibility rather than a reprieve.

Tier rankings and narratives in the 2024 Trafficking in Persons Report reflect an assessment of the following:

  • enactment of laws prohibiting severe forms of trafficking in persons, as defined by the TVPA, and provision of criminal punishments for trafficking crimes;
  • criminal penalties prescribed for human trafficking crimes which are sufficiently stringent and commensurate with those prescribed for other grave crimes;
  • implementation of human trafficking laws through vigorous prosecution of the prevalent forms of trafficking in the country and adequate sentencing of traffickers;
  • proactive victim identification measures with systematic procedures to guide law enforcement and other government-supported front-line responders in the process of victim identification;
  • government funding and partnerships with NGOs to provide victims with access to primary health care, counseling, and shelter, allowing them to recount their trafficking experiences to trained counselors and law enforcement in an environment of minimal pressure;
  • victim protection efforts that include access to services and shelter without detention and with legal alternatives to removal to countries in which victims would face retribution or hardship;
  • the extent to which a government ensures victims are provided with legal and other assistance and that, consistent with domestic law, proceedings are not prejudicial to victims’ rights, dignity, or psychological well-being;
  • the extent to which a government ensures the safe, humane, and, to the extent possible, voluntary repatriation and reintegration of victims;
  • governmental measures to prevent human trafficking, including efforts to curb practices identified as contributing factors to human trafficking, such as employers’ confiscation of foreign workers’ passports and allowing labor recruiters to charge fees to prospective migrants; and
  • governmental efforts to reduce the demand for commercial sex acts and extraterritorial sexual exploitation and abuse.

Tier rankings and narratives are NOT affected by the following:

  • efforts, however laudable, undertaken exclusively by nongovernmental actors in the country;
  • general public awareness events—government-sponsored or otherwise—lacking concrete ties to the prosecution of traffickers, protection of victims, or prevention of trafficking; and
  • broad-based law enforcement or developmental initiatives.

A Guide to the Tiers

Countries whose governments fully meet the TVPA’s minimum standards for the elimination of trafficking.

Countries whose governments do not fully meet the TVPA’s minimum standards but are making significant efforts to bring themselves into compliance with those standards.

Tier 2 Watch List

Countries whose governments do not fully meet the TVPA’s minimum standards but are making significant efforts to bring themselves into compliance with those standards, and for which:

  • the estimated number of victims of severe forms of trafficking is very significant or is significantly increasing and the country is not taking proportional concrete actions;
  • there is a failure to provide evidence of increasing efforts to combat severe forms of trafficking in persons from the previous year, including increased investigations, prosecutions, and convictions of trafficking crimes, increased assistance to victims, and decreasing evidence of complicity in severe forms of trafficking by government officials.

Countries whose governments do not fully meet the TVPA’s minimum standards and are not making significant efforts to do so.

The TVPA, as amended, lists additional factors to determine whether a country should be on Tier 2 (or Tier 2 Watch List) versus Tier 3:

  • the extent to which the country is a country of origin, transit, or destination for severe forms of trafficking;
  • the extent to which the country’s government does not meet the TVPA’s minimum standards and, in particular, the extent to which officials or government employees have been complicit in severe forms of trafficking;
  • reasonable measures that the government would need to undertake to be in compliance with the minimum standards in light of the government’s resources and capabilities to address and eliminate severe forms of trafficking in persons;
  • the extent to which the government is devoting sufficient budgetary resources to investigate and prosecute human trafficking, convict and sentence traffickers; and obtain restitution for victims of human trafficking; and
  • the extent to which the government is devoting sufficient budgetary resources to protect victims and prevent the crime from occurring.

In addition, the TVPA directs the Secretary of State to consider, as proof of a country’s failure to make significant efforts to fully meet the TVPA’s minimum standards, a government policy or pattern of: human trafficking; human trafficking in government-funded programs; forced labor (in government-affiliated medical services, agriculture, forestry, mining, construction, or other sectors); sexual slavery in government camps, compounds, or outposts; or employing or recruiting child soldiers.

The TVPA also provides that any country that has been ranked Tier 2 Watch List for two consecutive years and that would otherwise be ranked Tier 2 Watch List for the next year will instead be ranked Tier 3 in that third year.   The Secretary of State is authorized to waive the automatic downgrade only once, in that third year, based on credible evidence that a waiver is justified because the government has a written plan that, if implemented, would constitute making significant efforts to meet the TVPA’s minimum standards for the elimination of trafficking and is devoting sufficient resources to implement the plan.   The following year, a country must either go up to Tier 2 or down to Tier 3.   Additionally, the TVPA limits a country to one year on Tier 2 Watch List after that country received a waiver to stay on Tier 2 Watch List and was subsequently downgraded to Tier 3.

Funding Restrictions for Tier 3 Countries

Pursuant to the TVPA, governments on Tier 3 may be subject to certain restrictions on foreign assistance, whereby the President may determine not to provide U.S. government nonhumanitarian, nontrade-related foreign assistance as defined in the TVPA.   In addition, the President may determine to withhold funding for government official or employee participation in educational and cultural exchange programs in the case of certain Tier 3 countries.   Consistent with the TVPA, the President may also determine to instruct the U.S. Executive Director of each multilateral development bank and the International Monetary Fund to vote against and use their best efforts to deny any loans or other uses of the institutions’ funds to a designated Tier 3 country for most purposes (except for humanitarian, trade-related, and certain development-related assistance).   Alternatively, the President may waive application of the foregoing restrictions upon a determination that the provision to a Tier 3 country of such assistance would promote the purposes of the TVPA or is otherwise in the national interest of the United States.   The TVPA also authorizes the President to waive these restrictions if necessary to avoid significant adverse effects on vulnerable populations, including women and children.

Applicable assistance restrictions apply for the next Fiscal Year, which begins October 1, 2024.

  • TVPA Minimum Standards for the Elimination of Trafficking in Persons

Trafficking Victims Protection Act of 2000, Div. A of Pub. L. No. 106-386, § 108, as amended.

(1) The government of the country should prohibit severe forms of trafficking in persons and punish acts of such trafficking.

(2) For the knowing commission of any act of sex trafficking involving force, fraud, coercion, or in which the victim of sex trafficking is a child incapable of giving meaningful consent, or of trafficking which includes rape or kidnapping or which causes a death, the government of the country should prescribe punishment commensurate with that for grave crimes, such as forcible sexual assault.

(3) For the knowing commission of any act of a severe form of trafficking in persons, the government of the country should prescribe punishment that is sufficiently stringent to deter and that adequately reflects the heinous nature of the offense.

(4) The government of the country should make serious and sustained efforts to eliminate severe forms of trafficking in persons.

Indicia of “Serious and Sustained Efforts”

1. Whether the government of the country vigorously investigates and prosecutes acts of severe forms of trafficking in persons, and convicts and sentences persons responsible for such acts, that take place wholly or partly within the territory of the country, including, as appropriate, requiring incarceration of individuals convicted of such acts.   For purposes of the preceding sentence, suspended or significantly reduced sentences for convictions of principal actors in cases of severe forms of trafficking in persons shall be considered, on a case-by-case basis, whether to be considered an indicator of serious and sustained efforts to eliminate severe forms of trafficking in persons.   After reasonable requests from the Department of State for data regarding investigations, prosecutions, convictions, and sentences, a government which does not provide such data, consistent with a demonstrably increasing capacity of such government to obtain such data, shall be presumed not to have vigorously investigated, prosecuted, convicted or sentenced such acts.

2. Whether the government of the country protects victims of severe forms of trafficking in persons and encourages their assistance in the investigation and prosecution of such trafficking, including provisions for legal alternatives to their removal to countries in which they would face retribution or hardship, and ensures that victims are not inappropriately incarcerated, fined, or otherwise penalized solely for un-lawful acts as a direct result of being trafficked, including by providing training to law enforcement and immigration officials regarding the identification and treatment of trafficking victims using approaches that focus on the needs of the victims.

3. Whether the government of the country has adopted measures to prevent severe forms of trafficking in persons, such as measures to inform and educate the public, including potential victims, about the causes and consequences of severe forms of trafficking in persons, measures to establish the identity of local populations, including birth registration, citizenship, and nationality, measures to ensure that its nationals who are deployed abroad as part of a diplomatic, peacekeeping, or other similar mission do not engage in or facilitate severe forms of trafficking in persons or exploit victims of such trafficking, a transparent system for remediating or punishing such public officials as a deterrent, measures to pre-vent the use of forced labor or child labor in violation of international standards, effective bilateral, multilateral, or regional information sharing and cooperation arrangements with other countries, and effective policies or laws regulating foreign labor recruiters and holding them civilly and criminally liable for fraudulent recruiting.

4. Whether the government of the country cooperates with other governments in the investigation and prosecution of severe forms of trafficking in persons and has entered into bilateral, multilateral, or regional law enforcement cooperation and coordination arrangements with other countries.

5. Whether the government of the country extradites persons charged with acts of severe forms of trafficking in persons on substantially the same terms and to substantially the same extent as persons charged with other serious crimes (or, to the extent such extradition would be inconsistent with the laws of such country or with international agreements to which the country is a party, whether the government is taking all appropriate measures to modify or replace such laws and treaties so as to permit such extradition).

6. Whether the government of the country monitors immigration and emigration patterns for evidence of severe forms of trafficking in persons and whether law enforcement agencies of the country respond to any such evidence in a manner that is consistent with the vigorous investigation and prosecution of acts of such trafficking, as well as with the protection of human rights of victims and the internationally recognized human right to leave any country, including one’s own, and to return to one’s own country.

7. Whether the government of the country vigorously investigates, prosecutes, convicts, and sentences public officials, including diplomats and soldiers, who participate in or facilitate severe forms of trafficking in persons, including nationals of the country who are deployed abroad as part of a diplomatic, peacekeeping, or other similar mission who engage in or facilitate severe forms of trafficking in persons or exploit victims of such trafficking, and takes all appropriate measures against officials who condone or enable such trafficking.   A government’s failure to appropriately address public allegations against such public officials, especially once such officials have returned to their home countries, shall be considered inaction under these criteria.   After reasonable requests from the Department of State for data regarding such investigations, prosecutions, convictions, and sentences, a government which does not provide such data, consistent with a demonstrably increasing capacity of such government to obtain such data, shall be presumed not to have vigorously investigated, prosecuted, convicted, or sentenced such acts.

8. Whether the percentage of victims of severe forms of trafficking in the country that are non-citizens of such countries is insignificant.

9. Whether the government has entered into effective, transparent partnerships, cooperative arrangements, or agreements that have resulted in concrete and measurable outcomes with –

a. domestic civil society organizations, private sector entities, or international nongovernmental organizations, or into multilateral or regional arrangements or agreements, to assist the government’s efforts to prevent trafficking, protect victims, and punish traffickers; or

b. the United States toward agreed goals and objectives in the collective fight against trafficking.

10. Whether the government of the country, consistent with the capacity of such government, systematically monitors its efforts to satisfy the criteria described in paragraphs (1) through (8) and makes available publicly a periodic assessment of such efforts.

11. Whether the government of the country achieves appreciable progress in eliminating severe forms of trafficking when compared to the assessment in the previous year.

12. Whether the government of the country has made serious and sustained efforts to reduce the demand for –

a. commercial sex acts; and

b. participation in international sex tourism by nationals of the country.

  • Countries in the 2024 TIP Report that are not Party to the Protocol to Prevent, Suppress and Punish Trafficking In Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime
  • Congo, Republic of the
  • Korea, Democratic People’s Republic of the
  • Marshall Islands
  • Papua New Guinea
  • Solomon Islands

Between April 2023 and March 2024, Uganda became a State Party to the Protocol.

  • Global Law Enforcement Data

The 2003 reauthorization of the TVPA added to the original law a new requirement that foreign governments provide the Department of State with data on trafficking investigations, prosecutions, convictions, and sentences in order to fully meet the TVPA’s minimum standards for the elimination of trafficking (Tier 1).  The 2004 TIP Report collected this data for the first time.  The 2007 TIP Report showed for the first time a breakout of the number of total prosecutions and convictions that related to labor trafficking, placed in parentheses.

YEAR

PROSECUTIONS

Prosecutions – Labor Only

CONVICTIONS

Convictions – Labor Only

VICTIMS IDENTIFIED

Victims Identified – Labor Only

LEGISLATION

2017

17,471

869

7,135

332

96,960

23,906

5

2018

11,096

457

7,481

259

85,613

11,009

5

2019

11,841

1,024

9,548

498

118,932

13,875

7

2020

9,876

1,115

5,011

337

109,216

14,448

16

2021

10,572

1,379

5,260

374

90,354

21,219

15

2022

15,159

2,670

5,577

528

115,324

24,340

27

2023

18,774

3,684

7,115

1,256

133,943

42,098

14

The above statistics are estimates derived from data provided by foreign governments and other sources and reviewed by the Department of State. Aggregate data fluctuates from one year to the next due to the hidden nature of trafficking crimes, dynamic global events, shifts in government efforts, and a lack of uniformity in national reporting structures.

“As we work to help people disproportionately affected by human trafficking, including members of racial and ethnic minorities, women and girls, the LGBTQI+ community, and migrants, we remain committed to learning from and partnering with survivors to support their recoveries and to recruit their help in better spotting and preventing these too often overlooked crimes.”

President Joseph R. Biden Jr. President

“I believe history will show that this was the moment when we had the opportunity to lay the groundwork for the future of AI.  And the urgency of this moment must then compel us to create a collective vision of what this future must be.  A future where AI is used to advance the public interest.”

Vice President Kamala Harris, United States

“Combating trafficking requires a strong coalition of local and global partners to share resources and information, better equip front-line workers, and track and respond to evolving trafficking trends.”

Antony Blinken, Secretary of State

“The Intelligence Community in close partnership with law enforcement has been improving its production of detailed data analysis and reporting to better discern patterns and trends in human trafficking of migrants.  And with the help of new tools for conducting such analysis, we’re investing in these efforts, we think to good effect, as we also work to continually improve our connection to both local and federal law enforcement as well as the Department of Homeland Security to assist them in their work to countering the problem.”

Avril Haines, Director of National Intelligence 

“Survivors are the real experts.  Their experiences and their perspectives can help inform and motivate our policies so that we will do more, not less, and accelerate our efforts to combat this heinous cruelty.”

U.S. Representative Chris Smith   (R-NJ)

“Yet traffickers continue to operate with impunity.  Their crimes are receiving not nearly enough attention.  This must change.  We must invest much more in detection and protection.  We must strengthen law enforcement to bring criminals that commodify human beings to justice.  And we must do more to help survivors rebuild their lives.”

A ntonio Guterres, UN Secretary-General

“We need to step up our efforts to reach every trafficking victim, by strengthening detection, investigating cases, and prosecuting the criminals involved.  We also need to proactively identify, assist, and support survivors of this crime to truly leave no one behind.  This requires support from all sectors of society, from healthcare to social services to law enforcement.”

Ghada Waly, Executive Director of UNODC

“The scourge of human trafficking continues to evolve.  Civil unrest and war across the globe, natural disasters, climate change, and the advent and increasing reach of social media all pose significant challenges.”

Sameer Jain, Member of U.S. Advisory Council on Human Trafficking

“If we are to ever defeat trafficking, and this undoubtedly must be our shared ambition, effective approaches to prevention must be the bedrock upon which our anti-trafficking efforts are built.  Preventing trafficking in human beings from taking place is the best way to truly protect vulnerable groups and deprive traffickers of the illicit proceeds the crime generates.”

OSCE Secretary General Helga Maria Schmid

“Traffickers prey on the marginalized and most vulnerable.  But we are witnessing an emerging trend where the demographic profile of trafficking victims is also expanding, at pace with the digital developments in which we are living.”

Dr. Kari Johnstone , OSCE Special  Representative and Co-ordinator for Combating Human Trafficking

“We have to talk about those things that make us uncomfortable, especially if we want to work for an end to human trafficking.  Part of that is acknowledging that when we say nothing and do nothing in the face of many of these issues we are perpetuating the same violence that was done to us.”

Rafael Bautista, Member of the U.S. Advisory Council on Human Trafficking

“Building consensus around an affirmative vision is the first line of our tech diplomacy.  But the rules, the standards, the norms that societies follow are going to determine whether this technology is used for good or whether it’s used for ill.”

  • Tier Placements List
Argentina Estonia Poland
Australia Finland Seychelles
Austria France Singapore
The Bahamas Georgia Spain
Bahrain Germany Suriname
Belgium Guyana Sweden
Canada Iceland Taiwan
Chile Korea, Republic of United Kingdom
Colombia Lithuania United States of America
Cyprus Luxembourg
Czech Republic The Netherlands
Denmark Philippines
Albania Honduras Pakistan
Angola Hungary Palau
Antigua & Barbuda India Panama
Armenia Indonesia Paraguay
Aruba Iraq Peru
Azerbaijan Ireland Portugal
Bangladesh Israel Qatar
Barbados Italy Romania
Belize Jamaica Saudi Arabia
Bhutan Japan Senegal
Bolivia Jordan Sierra Leone
Bosnia and Herzegovina Kazakhstan Slovakia
Botswana Kenya Slovenia
Brazil Kosovo South Africa
Bulgaria Latvia Sri Lanka
Burundi Lesotho St. Lucia
Cabo Verde Malawi St. Vincent and Grenadines
Cameroon Malaysia Switzerland
Comoros Mauritania Tanzania
Costa Rica Mauritius Thailand
Congo, Democratic Republic of Mexico Timor-Leste
Cote d’Ivoire Micronesia Togo
Croatia Moldova Tonga
Ecuador Mongolia Trinidad and Tobago
Egypt Montenegro Tunisia
El Salvador Morocco Türkiye
Eswatini Mozambique Uganda
Ethiopia Namibia Ukraine
The Gambia New Zealand United Arab Emirates
Ghana Nigeria Uzbekistan
Greece North Macedonia Vietnam
Guatemala Norway Zambia
Guinea Oman
Algeria Guinea Bissau Marshall Islands
Benin Hong Kong Nepal
Burkina Faso Kuwait Niger
Central African Republic Kyrgyz Republic Rwanda
Chad Laos Serbia
Congo, Republic of Lebanon Solomon Islands
Curacao Liberia Tajikistan
Dominican Republic Madagascar Uruguay
Equatorial Guinea Maldives Vanuatu
Fiji Mali Zimbabwe
Gabon Malta
Afghanistan Djibouti Russia
Belarus Eritrea Sint Maarten
Brunei Iran South Sudan
Burma Korea, Democratic People’s Republic of Sudan
Cambodia Macau Syria
China, People’s Republic of Nicaragua Turkmenistan
Cuba Papua New Guinea Venezuela
Haiti
Libya
Somalia
Yemen

A note on Kiribati:  Reports during the 2024 reporting period indicated human trafficking crimes may have occurred in Kiribati.  However, information on anti-trafficking efforts from the Government of Kiribati and the nature and scope of trafficking in persons in Kiribati were insufficient to undertake a full assessment for the 2024 Report.  The Department of State will continue gathering information in the coming year and assess appropriate reporting for the 2025 TIP Report.

  • Regional Maps

The Regional Maps will be included in the PDF accessible online version.  Below includes the region-specific Global Law Enforcement Data.

Africa
YEAR PROSECUTIONS Prosecutions – Labor Only CONVICTIONS Convictions – Labor Only VICTIMS IDENTIFIED Victims Identified – Labor Only

LEGISLATION

2017 1,325 98 551 34 26,517 5,902 2
2018 1,253 37 1,190 29 24,407 3,749 2
2019 955 71 2,122 32 42,517 1,284 2
2020 1,493 251 382 107 28,538 6,947 8
2021 1,686 265 659 68 11,450 3,643 3
2022 2,477 388 904 139 21,790 5,436 5
2023 2,551 460 758 200 21,877 8,148 2
East Asia & Pacific
YEAR PROSECUTIONS Prosecutions – Labor Only CONVICTIONS Convictions – Labor Only VICTIMS IDENTIFIED Victims Identified – Labor Only

LEGISLATION

2017 2,949 77 3,227 72 4,915 669 0
2018 2,351 63 1,275 16 5,466 291 1
2019 3,276 86 3,662 20 14,132 7,687 2
2020 1,838 70 1,502 12 2,884 691 1
2021 1,440 73 1,066 60 3,348 859 0
2022 4,570 708 1,607 63 4,635 2,037 3
2023 3,390 398 1,802 97 6,543 1,161 2
Europe
YEAR PROSECUTIONS Prosecutions – Labor Only CONVICTIONS Convictions – Labor Only VICTIMS IDENTIFIED Victims Identified – Labor Only

LEGISLATION

2017 2,548 179 1,257 53 12,750 3,330 0
2018 2,394 234 1,379 80 16,838 2,675 1
2019 2,896 106 1,346 41 17,383 1,369 2
2020 2,355 101 1,291 33 18,173 1,082 2
2021 3,285 86 1,905 92 21,347 2,124 5
2022 2,932 169 1,668 67 24,528 2,497 6
2023 3,147 201 1,667 93 32,996 4,448 4
Near East
YEAR PROSECUTIONS Prosecutions – Labor Only CONVICTIONS Convictions – Labor Only VICTIMS IDENTIFIED Victims Identified – Labor Only

LEGISLATION

2017 974 112 104 11 1,834 53 0
2018 738 10 155 7 2,675 83 0
2019 788 44 419 22 3,619 35 0
2020 533 106 414 84 3,461 1,827 0
2021 869 356 353 88 3,440 1,127 1
2022 644 173 545 85 2,980 1,790 0
2023 2,258 1,344 770 390 3,450 1,596 2
South & Central Asia
YEAR PROSECUTIONS Prosecutions – Labor Only CONVICTIONS Convictions – Labor Only VICTIMS IDENTIFIED Victims Identified – Labor Only

LEGISLATION

2017 8,105 264 1,063 48 40,857 11,813 2
2018 3,102 41 2,465 9 24,544 1,841 1
2019 2,602 616 1,156 349 28,929 3,227 1
2020 2,747 532 834 74 45,060 3,275 3
2021 1,910 479 438 17 38,426 12,426 2
2022 3,304 1,118 597 104 49,715 11,161 1
2023 6,041 1,101 1,245 368 50,815 23,089 0
Western Hemisphere
YEAR PROSECUTIONS Prosecutions – Labor Only CONVICTIONS Convictions – Labor Only VICTIMS IDENTIFIED Victims Identified – Labor Only

LEGISLATION

2017 1,571 139 969 114 10,011 2,139 1
2018 1,252 72 1,017 177 11,683 2,370 0
2019 1,324 101 843 34 12,352 273 0
2020 910 55 588 27 11,100 626 2
2021 1,382 120 794 49 12,343 1,040 4
2022 1,232 114 256 70 11,676 1,419 12
2023 1,387 180 873 108 18,292 3,656 4
  • Stopping Human Trafficking and Sexual Exploitation and Abuse (SEA) by International Peacekeepers and Civilian Personnel

This section summarizes actions taken by the United Nations (UN), the North Atlantic Treaty Organization (NATO), and the Organization for Security and Co-operation in Europe (OSCE) to prevent trafficking in persons or the exploitation of victims of trafficking during calendar year 2023.

Total Number of Peacekeeping and Support Personnel 63,170

 

2,264  4,477
Total Number of Missions 11  14  2
Prevention Policy “Special Measures for Protection from Sexual Exploitation and Sexual Abuse” (2003) “Code of Conduct for Staff and Mission Members”

“Staff Instruction No. 33/2023:  Whistleblowing and Protection against Retaliation” (adopted 3 October 2023)

“Staff Instructions No. 0032/2022: Prevention of Sexual Exploitation and Abuse” (adopted 20 June 2022)

“Staff Instruction No. 11/2004: Preventing the Promotion/Facilitation of Trafficking in Human Beings” (adopted 22 January 2004)

 

 Human Security Unit (political)

International Military Staff – Gender Advisor (Military Advice)

Heads of NATO Military Bodies (e.g. SACEUR, SACT)

Lead Office Responsible for Implementation The Conduct and Discipline Service (CDS)

The Office of Internal Oversight Services (OIOS)

Secretary General

Department of Human Resources

Office of Internal Oversight

 

 

For preventing human trafficking, conflict-related sexual violence and SEA, training is done via pre-deployment and during any missions or operations.  Nations are responsible for the provision of pre-deployment training of their personnel in accordance with NATO standards.  Heads of NATO Bodies are responsible for providing training to their personnel.
Prevention Training Pre-deployment and at mission, including an e-learning program Pre-deployment

OSCE Prevention of Sexual Exploitation and Abuse (PSEA) mandatory online training launched in October 2023.

Introductory workshop for the PSEA Focal Points held on 15 September 2023.

 

 

None reported
Number of Allegations in 2023 101 allegations were made against military, police, and civilian personnel. Ninety percent of the allegations were in the Democratic Republic of the Congo and the Central African Republic.

This is only the second time in the past 10 years that 100 or more allegations were recorded in one year.

22 of the allegations affected children.

The OSCE Department for Human Resources had no record of any reported allegations of sexual exploitation or sexual abuse in 2023.

The OSCE Office of Internal Oversight did not receive any allegations of SEA in 2023.

 

 

No reported allegations – NATO relies on contributing countries to report allegations.
New Initiatives UNHCR is piloting its participation in the Misconduct Disclosure Scheme (MDS), which facilitates the sharing of misconduct data between employers and prevents the rehiring of perpetrators across NGOs and other participating agencies. UNHCR uses MDS as a complement to its use of ClearCheck.  UNOPS planned to pilot its participation in MDS in early 2024.  In accordance with General Assembly resolution 77/278, the Secretariat is exploring “whether ClearCheck database and the Misconduct Disclosure Scheme can complement each other.”

The World Food Program (WFP) and IOM are developing a multilingual multimedia package of accessible information on protection from SEA for beneficiaries.

In 2023, the UN Secretariat piloted a reinforcement training package for uniformed commanders, in cooperation with Member States.  It provides targeted training support for commanders on conduct and discipline, with a focus on the prohibition of SEA.  The package will be rolled out in 2024.

The OSCE appointed PSEA focal points in April 2023 to raise awareness of Staff Instruction 32 and provide guidance on how to prevent and respond to incidents.

In May 2023, the OSCE revised its contractual arrangements with external providers, including the General Conditions of Contract for both goods and services, as well as the standard Implementing Partner Agreement.  These revisions now incorporate clauses mandating contractors to implement suitable measures for preventing and addressing SEA by their employees or any individuals engaged in providing services to the OSCE.

 

 

In July 2023, NATO adopted its new policy on combating trafficking in human beings. The aim of this new policy was to provide a coherent, consistent, and integrated political framework for NATO’s role in combating trafficking in human beings. This policy applies to all NATO personnel in all Alliance operations, missions, and activities, wherever NATO operates, from peacetime to crisis and conflict, including stabilization and post-conflict, and should be considered within the broader framework policies and guidance within NATO, including the wider Human Security Approach and Guiding Principles. This Security Approach allows for a more comprehensive view of the human environment, consequently enhancing operational effectiveness and contributing to lasting peace and security.

Links for Additional Information

 

 

  • Relevant International Conventions

The chart below shows the Ratification, Accession (a), or Acceptance (A) of relevant international conventions for those countries that have ratified, acceded to, or accepted any such conventions between April 2023 and March 2024.  A complete list that includes the status of all of the countries covered by the Trafficking in Persons Report is available at: https://www.state.gov/international-conventions-relevant-to-combating-trafficking-in-persons/

Country

UN Protocol to Prevent, Suppress and Punish Trafficking in Persons (2000)

Optional Protocol to the Convention on the Rights of the Child on the Sale of Children, Child Prostitution and Child Pornography (2000)

Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict (2000)

ILO

Convention 29, Forced Labour (1930)

ILO Protocol of 2014 to the Forced Labour Convention

ILO

Convention 105, Abolition of Forced Labour (1957)

ILO

Convention 182,

Elimination of Worst Forms of Child Labour (1999)

ILO

Convention 189, Domestic Workers (2011)

Brunei-Darussalam

2020 (a)

2006

2016

2024

_

_

2008

_

Mexico

2003

2002

2002

1934

2024

1959

2000

2020

Seychelles

2004

2012

2010

1978

_

1978

1999

2024

Uganda

2024

2001

2002

1963

_

1963

2001

_

  • International, Regional, and Sub-Regional Organizations Combating Trafficking in Persons

For the 2024 Trafficking in Persons Report, the Framework Documents and other Relevant Guidance section has been consolidated to show only documents published during the reporting year: April 1, 2023 – March 31, 2024.  If you would like to review documents from previous years, please refer to the 2023 Trafficking in Persons Report .

(2023)

UN General Assembly Resolution on Improving the coordination of efforts against trafficking in persons (A/RES/78/228) (2023)

(A/78/119) (2023)

HRC Resolution on Trafficking in Persons, especially women and children (A/HRC/RES/53/9) (2023)

(2023)

(2023)

(2024)

UN Special Rapporteur on Trafficking in Persons, Especially Women and Children

UN Special Rapporteur on Contemporary Forms of Slavery

UN Special Rapporteur on the Sale of Children, Child Prostitution, and Child Pornography

https://www.ilo.org

(2023)

(2023)

(2024)

(2024)

(2024)

(2024)

(2023)

(EU/Horn of Africa Migration Route Initiative)

(2023)

(2024)

(2023)

(2023)

(2023)

(2023)

(2024)

ASEAN Senior Officials Meeting on Transnational Crime

(2023)

(2023)

(2023)

(2023)

Bali Process Working Group on Trafficking in Persons

No relevant Framework Documents or other Relevant Guidance were published during the reporting period.

(in Russian only)

No relevant Framework Documents or other Relevant Guidance were published during the reporting period.

No relevant Framework Documents or other Relevant Guidance were published during the reporting period.

United Nations Action for Cooperation against Trafficking in Persons

Regional COMMIT Task Force

(2023)

(2023)

(2024)

(2024)

Task Force against Trafficking in Human Beings

Expert Group on Children at Risk

Task Force Against Trafficking in Human Beings

(2023)

(2023)

(2023)

(2024)

(2024)

(2024)

(2024)

Group of Experts on Action Against Trafficking in Human Beings

(2023)

(2023)

(2023)

The ECOWAS Regional Network of National Focal Institutions Against Trafficking in Persons Plus

Anti-Trafficking Unit

(2024)

(2024)

EU Anti-Trafficking Coordinator

EU Network of National Rapporteurs and Equivalent Mechanisms

EU Civil Society Platform against Trafficking in Human Beings

Coordination Group of the EU agencies working against trafficking in human beings

(updated in 2023)

(2024)

(2024)

No relevant Framework Documents or other Relevant Guidance were published during the reporting period.

(2023)

(2023)

(2024)

(2024)

Department of Public Security and Department against Transnational Organized Crime

(2023)

(2024)

(2024)

OECD Task Force on Countering Illicit Trade

No relevant Framework Documents or other Relevant Guidance were published during the reporting period.

(2023)

(2023)

(2023)

(2023)

(2023)

(2023)

(2024)

(2024)

(2024)

(2024)

Special Representative and Co-ordinator for Combating Trafficking in Human Beings

Office for Democratic Institutions and Human Rights

International Survivors of Trafficking Advisory Council

No relevant Framework Documents or other Relevant Guidance were published during the reporting period.

The Liaison Officers Network to Combat Migrant Smuggling and Trafficking in Persons

(2023)

(2023)

  • Annual Report to Congress on the Use of Child Soldiers under Section 405(c) of the Child Soldiers Prevention Act of 2008

This report is submitted in accordance with section 405(c) of the Child Soldiers Prevention Act of 2008 (22 U.S.C. 2370c-2(c)) (CSPA).  Section 1 lists the countries identified as being in violation of the standards under the CSPA in 2023.  Section 2 provides a description and the amounts of assistance withheld pursuant to section 404(a) of the CSPA.  Section 3 provides a list of waivers or exceptions exercised under the CSPA.  Section 4 contains the justifications for such waivers.  Section 5 provides a description and the amounts of assistance provided to countries pursuant to such waivers.

Section 1. Countries in Violation of the Standards Under the CSPA in 2023.

The Secretary of State identified the following countries as having governmental armed forces, police, or other security forces or government-supported armed groups that recruited or used child soldiers within the meaning of section 404(a) of the CSPA during the reporting period of April 1, 2022 – March 31, 2023: Afghanistan, Burma, Central African Republic (CAR), Democratic Republic of the Congo (DRC), Egypt, Eritrea, Iran, Libya, Mali, Russia, Rwanda, Somalia, South Sudan, Syria, Türkiye, Venezuela, and Yemen.

Section 2. Description and Amount of Assistance Withheld Pursuant to Section 404(a).

No security assistance subject to section 404(a) of the CSPA was planned to be provided to Afghanistan, Burma, Eritrea, Iran, Mali, Russia, Rwanda, South Sudan, Syria, or Venezuela in fiscal year (FY) 2024.

Section 3. List of Waivers or Exceptions Exercised under Section 404(a).

On September 15, 2023, the President determined that it is in the national interest of the United States to waive the application of the prohibition in section 404(a) of the CSPA with respect to Egypt; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Türkiye for International Military Education and Training (IMET) and Peacekeeping Operations (PKO) assistance, issuance of direct commercial sales (DCS) licenses, and support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333, to the extent that the CSPA would restrict such assistance or support; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Libya and Somalia to allow for the provision of IMET and PKO assistance, and support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333, to the extent that the CSPA would restrict such assistance or support; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to the Democratic Republic of the Congo to allow for the provision of IMET and PKO assistance and issuance of DCS licenses in connection with the reexport of transport aircraft, to the extent that the CSPA would restrict such assistance; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to the Central African Republic and Yemen to allow for the provision of IMET and PKO assistance, to the extent that the CSPA would restrict such assistance; and to waive the application of the prohibition in section 404(a) of the CSPA to allow for the issuance of DCS licenses related to other U.S. government assistance for the above countries and, with respect to the Russian Federation, solely for the issuance of DCS licenses in connection with the International Space Station (ISS).  The President has further certified that the governments of the above countries are taking effective and continuing steps to address the problem of child soldiers.

Section 4. Justifications for Waivers and Exceptions.

Pursuant to section 404(c) of the Child Soldiers Prevention Act of 2008 (CSPA) (22 U.S.C. 2370c-1(c)), the President has determined that it is in the national interest of the United States to waive the application of the prohibition in section 404(a) of the CSPA with respect to Egypt; to waive, in part, the application of the prohibition with respect to the Central African Republic, the Democratic Republic of the Congo, Libya, Somalia, Türkiye, and Yemen, including to allow for the issuance of direct commercial sales (DCS) licenses related to other U.S. government assistance for these countries that is not subject to the prohibition in section 404(a); and, with respect to Russia, to waive, in part, the application of the prohibition solely for DCS licenses in connection with the International Space Station.  The President has further certified that the governments of the above countries are taking effective and continuing steps to address the problem of child soldiers.  The justification for this determination and certification with respect to each country is set forth in this Memorandum.

The Central African Republic (CAR)

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to CAR to allow for the provision of International Military Education and Training (IMET) and Peacekeeping Operations (PKO) assistance and has certified that the CAR Government (CARG) is taking effective and continuing steps to address the problem of child soldiers.

Armed groups in CAR continue to threaten civilians and pose a longstanding risk to stability.  The waiver for PKO and IMET assistance for CAR will support the professionalization of the military to better provide security to the people of CAR while respecting human rights and international humanitarian law (IHL).  Additionally, IMET programming allows the United States to invest in CAR military officers to promote professional military education and foster relationships with foreign military personnel rooted in democratic values.

The CARG is taking effective and continuing steps to address the problem of child soldiers through meaningful engagement with U.S. and UN officials in seeking assistance to eradicate trafficking in persons, including the recruitment or use of child soldiers by CAR security forces and armed groups.  Recent efforts have included the adoption of a national plan to counter trafficking in children, government directives prohibiting the presence of children around military bases, and collaboration with the UN and implementing partners to reintegrate children affected by conflict.

The Democratic Republic of the Congo (DRC)

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to DRC to allow for the provision of IMET and PKO assistance and issuance of licenses for DCS in connection with the reexport of transport aircraft and has certified that the Government of the DRC (GDRC) is taking effective and continuing steps to address the problem of child soldiers.

The proliferation of armed groups amidst ongoing conflict in eastern DRC continues to threaten security and stability for the people of the DRC.  IMET and PKO assistance for the DRC enables the United States to continue professionalization efforts of the Armed Forces of the Democratic Republic of the Congo (FARDC) by enhancing its capacity to provide security within its territory while respecting human rights and IHL.  IMET and PKO assistance provide mechanisms to support security sector governance reforms and training in areas such as military justice, civil-military relations, respect for human rights and IHL, military engineering, and resource management and logistics, which enhance security and help make the FARDC a more transparent, accountable institution.

The GDRC is taking effective and continuing steps to address the problem of child soldiers through sustained commitment to implement its 2012 Action Plan to end and prevent the recruitment and use of child soldiers in partnership with the UN.  Additionally, in 2022 the GDRC adopted a national strategy for the implementation of the Demobilization, Disarmament, Community Recovery and Stabilization Program, which signals an important step in prioritizing children affected by armed conflict, particularly in eastern DRC.

The President has determined it is in the national interest of the United State to waive, in full, the application of the prohibition in section 404(a) of the CSPA with respect to Egypt and has certified that the Government of Egypt is taking effective and continuing steps to address the problem of child soldiers.

Egypt is an important U.S. partner in counterterrorism, anti-trafficking, and regional security operations, which advance both U.S. and Egyptian security. The decades-long defense partnership is a pillar for regional stability and key to securing peace with Israel, supporting the Multinational Force and Observers missions, and enhancing security of the Suez Canal.  Since 1978, the United States has provided more than $54 billion in military assistance for Egypt, which has contributed to Egypt’s capabilities to protect and defend its land, air, and maritime borders and to confront an evolving terrorist threat, including in the Sinai Peninsula.

The Government of Egypt is taking effective and continuing steps to address the problem of child soldiers, even as the scope and intensity of the counterterrorism fight in the Sinai continues to see a significant downturn; 2023 is on track to report the lowest levels of violence in the Sinai since the conflict began in 2011.  The U.S. government is not aware of the Egyptian military, police, or other security forces recruiting or using child soldiers.  Consistent with Egypt’s domestic laws and its obligations under the Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict, the Egyptian government effectively prohibits persons under the age of 18 from being forcibly recruited into the armed forces.  The Government of Egypt provides critical influence in addressing the recruitment or use of child soldiers by tribal militias, and the U.S. government will continue to engage the Egyptian government regarding reports of recruitment of child soldiers by government-supported Sinai tribal forces.

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Libya to allow for the provision of IMET and PKO assistance and DoD support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 and has certified that the Government of National Unity (GNU) in Libya is taking effective and continuing steps to address the problem of child soldiers.

The U.S. government selected Libya as a priority country for implementation of the U.S. Strategy to Prevent Conflict and Promote Stability.  The Department of State further assesses that in Libya the most durable solution to the unlawful recruitment of child soldiers, including by GNU-aligned units and the self-styled Libyan National Army, is a negotiated political settlement that ends Libya’s instability and the cycles of conflict.  IMET assistance will facilitate English language proficiency to improve interoperability and promote civil-military relations, including civilian control of a unified military.  PKO assistance will build upon the October 2020 ceasefire and support U.N. efforts to advance Libya’s transition to a unified, democratically elected, and inclusive political system based on respect for human rights.  PKO provides the U.S. government a tool to support UNSMIL in its ceasefire monitoring function.  Department of Defense support will build the capacity of Libyan military institutions in support of progress towards civilian-controlled, accountable, defense institutions that uphold human rights, combat terrorism, and address security challenges.

The GNU is taking effective and continuing steps to address the problem of child soldiers through engagement with the UN and the U.S. government in the context of our recurring bilateral Security Dialogue.  Through cooperation with UNSMIL, representatives of the Libyan 5+5 Joint Military Commission, comprised of senior military officers from both the east and west, engage with UNICEF on preventing child soldier recruitment.  The U.S. government is not aware of the GNU’s military, police, or other governmental security forces recruiting or using child soldiers.  Further, GNU security sector leaders provide critical influence to prevent and end the recruitment or use of child soldiers by armed groups in Libya and mitigate the reliance on external forces or groups for internal security.

Russian Federation

The President has determined it is in the national interest of the United State to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to the Russian Federation to allow for issuance of licenses for DCS solely in connection with the International Space Station (ISS) and has certified that the Government of the Russian Federation is taking effective and continuing steps to address the problem of child soldiers.

It is in the U.S. national interest to work with Russia to maintain the safety of ISS operations.  Maintaining longstanding U.S.-Russia ISS operations requires the ability to issue DCS licenses for defense articles and defense services in support of the ISS until the planned termination of its operation, which the National Aeronautics and Space Administration estimates will be in 2030.  This waiver will allow such activities to continue and will enable the issuance of licenses necessary to support the safe operation of the ISS, U.S.-Russia integrated crew missions to the ISS, and the safety of U.S. and other personnel onboard the ISS.

The Russian Federation is taking effective and continuing steps to address the problem of child soldiers.  In accordance with the Russian Federation’s Law on the Ratification of the Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict of 2008, the Government of the Russian Federation effectively prohibits persons under the age of 18 from being forcibly recruited into the armed forces.

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Somalia to allow for the provision of IMET and PKO assistance, and DoD support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 and has certified that the Federal Government of Somalia (FGS) is taking effective and continuing steps to address the problem of child soldiers.

Foreign terrorist organizations including al-Shabaab continue to threaten security and stability for the people of Somalia.  The waiver for IMET and PKO assistance for Somalia enables the United States to continue professionalization efforts of the Somali National Army (SNA) by enhancing their capacity to provide security within their territory while respecting human rights and IHL.  Further, a waiver for support provided by the Department of Defense pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 will allow for U.S. government assistance to build the Somali military’s capacity to conduct effective, sustained counterterrorism operations against al-Shabaab and help reinforce U.S. values, including those related to preventing and ending the unlawful recruitment or use of child soldiers.

The FGS is taking effective and continuing steps to address the problem of child soldiers through sustained commitment to implement its 2019 “road map” to accelerate progress on its 2012 Action Plan on ending the recruitment and use of children by the Somali National Armed Forces in partnership with the UN.  The SNA’s Child Protection Unit continued to make progress in implementing screening procedures, training, and disseminating media to prevent the recruitment and use of child soldiers.  The FGS also continued implementation of standard operating procedures for the handover of children allegedly associated with armed groups.

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Türkiye for IMET and PKO assistance, issuance of DCS licenses, and DoD support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 and has certified that the Government of Türkiye is taking effective and continuing steps to address the problem of child soldiers.

Türkiye has been an important U.S. security partner and valued NATO Ally since 1952, regulating passage, in accordance with international law, through the straits of the Bosporus and the Dardanelles, which link the Black Sea with the Mediterranean. Further, Türkiye’s military capability and geographic location are vital to the United States’ integrated deterrence strategy and ability to respond to regional events including with respect to counterterrorism, humanitarian assistance, and disaster relief operations. Türkiye’s support, including defense and security cooperation, to NATO Allies and partners deters malign influence in the region. This waiver will assist in maintaining NATO cohesion and continued interoperability, bolster regional security, and advance bilateral cooperation.

The Government of Türkiye is taking effective and continuing steps to address the problem of child soldiers, including those present in elements of the Syrian National Army receiving support from the Government of Türkiye.  The United States is not aware of the Turkish military, police, or other security forces recruiting or using child soldiers.  Consistent with Türkiye’s domestic laws and its obligations under the Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict, the Turkish military effectively prohibits persons under the age of 18 from being forcibly recruited into the armed forces.  Further, the Government of Türkiye provides critical influence in addressing the problem of child soldiers with respect to the Syrian National Army.

The President has determined that it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Yemen to allow for provision of IMET and PKO assistance and has certified that the Government of the Republic of Yemen (ROYG) is taking effective and continuing steps to address the problem of child soldiers.

It is in the U.S. national interest to support UN-led efforts to achieve an inclusive negotiated political resolution to the conflict in Yemen.  The waiver for IMET assistance for Yemen enables the United States to continue to support professionalization and interoperability efforts of the Yemeni Armed Forces (YAF) by enhancing their capacity to provide inclusive security within their territory while respecting human rights and IHL.  Further, this waiver will improve the YAF’s capacity to conduct effective, sustained counterterrorism operations, ensuring freedom of navigation through the Bab Al-Mandeb Strait, and securing the space for restoring effective governance institutions.

The ROYG is taking effective and continuing steps to address the problem of child soldiers through sustained commitment to implement its 2018 “road map” to accelerate progress on its 2014 Action Plan to end and prevent the recruitment of children by Yemeni Armed Forces in partnership with the UN.  The ROYG established child protection units within all military regions, issued directives banning child recruitment, and conducted numerous senior government field visits to monitor the implementation of screening procedures to prevent child recruitment and remove children from military units.

Section 5. Description and Amount of Assistance Provided Pursuant to a Waiver.

The information provided below only includes assistance obligated as of April 20, 2024.  Additional assistance will be obligated during FY 2024.

Central African Republic

International Military Education Training $101,124

As of April 20, 2024, IMET funding was obligated for the following activity: professional military education and training.

Democratic Republic of the Congo

International Military Education Training $177,238

International Military Education Training $1,352,782

International Military Education Training $31,284

Peacekeeping Operations $31,917,530.44

As of April 20, 2024, PKO funding was obligated for Somali National Army and Somali Ministry of Defense for the following activities:

logistical support; advisory support; equipment; and program oversight.

10 U.S.C. 333 $4 ,668,640.56

As of April 20, 2024, 333 funding was obligated for the following activities: training and equipment.

International Military Education Training $182,098

International Military Education Training $339,662

As of April 20, 20, 2024, IMET funding was obligated for the following activity: professional military education and training.

  • GLOSSARY OF ABBREVIATIONS
ASEAN Association of Southeast Asian Nations
GBV Gender-based Violence
ECOWAS Economic Community of West African States
EU European Union
EUROPOL European Union Agency for Law Enforcement Cooperation
FARC Revolutionary Armed Forces of Colombia
GRETA Council of Europe’s Group of Experts on Action against Trafficking in Human Beings
IDP Internally displaced person
ILO International Labour Organization
INTERPOL International Criminal Police Organization
IOM International Organization for Migration
ISIS Islamic State of Iraq and Syria
IUU Illegal, Unreported, and Unregulated
LGBTQI+ Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex
MOU Memorandum of Understanding
NAP National Action Plan
NGO Nongovernmental organization
NRM National Referral Mechanism
SOPs Standard Operating Procedures
OAS Organization of American States
OSCE Organization for Security and Co-operation in Europe
UN United Nations
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
UNODC United Nations Office on Drugs and Crime
UN TIP Protocol (Palermo Protocol) Protocol to Prevent, Suppress and Punish Trafficking in Persons,

Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime

Notes:  Local currencies have been converted to U.S. dollars ($) using the currency exchange rates reported by the U.S. Department of the Treasury on December 31, 2023.

  • Acknowledgments

The Staff of the Office to Monitor and Combat Trafficking in Persons Is:

Mekhribon Abdullaeva

Sylvia Amegashie

Katrina Askew-Alston

Andrea Balint Garza

Shonnie R. Ball

Suzanne Balson

Matt Becker

Getoria Berry

Brooke Beyer

Caris Boegl

Michelle C. Bloom

Alexandria Boling

Katherine Borgen

Gregory Borgstede

Kelsey Brennan

Joshua Bull

Carla M. Bury

Renée Callender

Jessica Cisneros

Kate Cooper

Camila Crowley

Reena Dalwadi

Sarah Davis

Steven Davis

Anca DiGiacomo

Daniel Evensen

Anna Fraser

Lauren Frey

Mark Forstrom

Lucia Gallegos

Beatriz Garcia Velazquez

Brianna Gehring

Chauna Gibson

Natasha Greenberg

Andrew Grimmer

Takiyah Golden

Denise Harrison

Jocelyn Harrison

Emmanuel Hector

Caitlin B. Heidenreich

Ashley Hernandez

J. Brett Hernandez

Matthew Hickey

Crystal Hill

Megan Hjelle-Lantsman

Jennifer M. Ho

Marta Hoilman

Ariana Holly

Moira Honohan

Renee Huffman

Veronica Jablonski

Harold Jahnsen

Sarah Jennings

Devin Johnson

Maurice W. Johnson

Kari A. Johnstone

Chelsea Kaser

Patrick Kelly

Emily Korenak

Kendra L. Kreider

Mary Lagdameo

Valery Lavigne

James Lensen-Callas

Rebecca Lesnak

Abigail Long

Samantha Lord

Jean McAnerney

Cameron Malcom

Bryan Marcus

LaTina Marsh

Sunny Massa

Kerry McBride

Rendi McCoy

Tamara McCoy

Maura K. McManus

Leah F. Meyer

Rebecca Morgan

Ericka Moten

Ryan Mulvenna

Dan Muncaster

Cristina Narvaez

Amy O’Neill Richard

Zury Palencia

Lauren Parnell

Ashlei Perry

Marissa Pietrobono

Sanjana Polapragada

Justin D. Pollard

David Rabinovich

Patrick Read

Andrea E. Reed

Casey Risko

Angie Rivas

Amy Rustan Haslett

Manith Sarik

Aram Schvey

Tori Jamese Scott-Senghor

Adrienne Sgarlato

Jessica Singh

Stephen Shade

Kaela Shear

Soumya Silver

Cornelius Slayton

Susan Snyder

Megan Stalder

Latoshae Summers

Desirée Suo Weymont

Jamie Sutter

Francesca J. Tadle

Atsuki Takahashi

James Taylor

Anna Thiessen

Cecilia Thompson

Juan Jose Tierjo

Wanda Toney

Andrea Ugolini

Melissa Verlaque

Matthew Villemain

Myrna E. Walch

Frances Wallman

Bianca Washington

Pauline Werner

Danielle (Nikki) Wetsel

Terry Whenry

Sharifa White

Joshua Williams

Willow Williamson

Joshua Youle

Salia Zouande

Special thanks to Brian Piaquadio, Julia Maruszewski, LeGrand Latney, Kimberly Ross, and the creative services team at Global Publishing Solutions.  Special thanks also to the ECA Bureau and technical project managers Tasha Wilkinson and Ed Williams.

Special thanks to Bukola Oriola, Dawn Schiller, Christine Cesa, Jeri Moomaw, Harold D’Souza, Jessa Crisp, Jill Brogdon, Megan Lundstrom, Rafael Bautista, Tanya Gould, and other subject matter experts with lived experience of human trafficking from the Department of State’s Human Trafficking Expert Consultant Network for their contributions to the TIP Report.

On This Page

U.s. department of state, the lessons of 1989: freedom and our future.

  • Case report
  • Open access
  • Published: 26 June 2024

Hemothorax caused by injury of musculophrenic artery after ultrasound-guided percutaneous liver biopsy: a case report

  • Jing-ru Yang 1 ,
  • Jian Li 2 ,
  • Xiao-juan Tian 1 ,
  • Zhuo-xi Xue 1 &
  • Xiao-yan Niu 1  

Journal of Medical Case Reports volume  18 , Article number:  303 ( 2024 ) Cite this article

Metrics details

Hemorrhage is the most common major complication after liver biopsy. Hemothorax is one type of bleeding and is very rare and dangerous. Several cases of hemothorax subsequent to liver biopsy have been documented, primarily attributed to injury of the intercostal artery or inferior phrenic artery and a few resulting from lung tissue damage; however, no previous case report of hemothorax caused by injury of musculophrenic artery after liver biopsy has been reported.

Case presentation

A 45-year-old native Chinese woman diagnosed with primary biliary cirrhosis due to long-term redness in urination and abnormal blood test indicators was admitted to our hospital for an ultrasound-guided liver biopsy to clarify pathological characteristics and disease staging. A total of 2 hours after surgery, the patient complained of discomfort in the right chest and abdomen. Ultrasound revealed an effusion in the right thorax and hemothorax was strongly suspected. The patient was immediately referred to the interventional department for digital subtraction angiography. Super-selective angiography of the right internal thoracic artery was performed which revealed significant contrast medium extravasation from the right musculophrenic artery, the terminal branch of the internal thoracic artery. Embolization was performed successfully. The vital signs of the patient were stabilized after the transarterial embolization and supportive treatment.

This case draws attention to the musculophrenic artery as a potential source of hemorrhage after percutaneous liver biopsy.

Peer Review reports

Percutaneous ultrasound-guided liver biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases [ 1 ]. Hemorrhage is the most common major complication after liver biopsy, and bleeding of any kind has been reported to occur in up to 11% of patients [ 2 ]. Hemothorax is much less common than other types of hemorrhage and can be very dangerous and life-threatening [ 3 ]. The initial management of hemothorax should involve angiographic embolization, ensuring comprehensive screening of all potentially injured arteries including intercostal arteries and all possible blood supply arteries to the diaphragm [ 4 ]. Here, we report a case of hemothorax caused by injury of musculophrenic artery after percutaneous liver biopsy, which, to our knowledge, has never been reported.

A 45-year-old native Chinese woman was diagnosed with primary biliary cirrhosis due to long-term redness in urination and abnormal blood test indicators. She had no diarrhea, vomiting, or abdominal pain. Vital signs and other physical examinations were normal. Liver function tests showed alanine transaminase (ALT) 104 U/L, aspartate transaminase (AST) 95 U/L, alkaline phosphatase (ALP) 269 U/L, gamma glutamyl transpeptidase (GGT) 440 U/L, and serum total bilirubin 23 µmol/L. Immunological tests were as follows: anti-mitochondria antibody (AMA) positive, AMA-M2-3E(BPO, a recombinant fusion protein that expresses three lipoyl-binding functional domains of BCOADH-E2,PDH-E2,OGDH-E2) positive(+++), and antinuclear autoantibodies (ANA) positive (++). The results of all hepatitis virus tests were negative. Ultrasound showed a coarse echotexture of the liver, and computed tomography (CT) showed abnormal liver morphology, with atrophy of the right lobe and enlargement of the left lobe. Both modalities displayed cirrhosis, but there were no focal hepatic lesions. She has had mitral valve replacement (bioprosthetic valve) for 1 year. She denied any other chronic illnesses, as well as neurological and psychiatric disorders. There is no known family history of hepatobiliary, gastrointestinal, or other genetic diseases. The patient was admitted to our hospital for an ultrasound-guided liver biopsy to clarify pathological characteristics and disease staging. The informed consent was obtained from the patient.

Preoperative tests showed that the hemoglobin, prothrombin time, bleeding time, and platelet count were normal and she was not taking any anticoagulants. Ultrasound-guided liver biopsy was carried out with GE Logiq E9 (GE Medical Systems Ultrasound and Primary Care Diagnostics, LLC, Wauwatosa, WI, USA) and a convex array probe (C6-1). The patient was in the left decubitus position and segment VI of the right lobe was chosen as the target of biopsy. A BARD automatic biopsy gun with an 18 G needle was applied and two strips of liver tissue were obtained (Fig.  1 ). During the puncture procedure, electrocardiogram monitoring was normal, blood pressure (BP) was 100/67 mmHg, heart rate (HR) was 80 beats per minute, and pulse blood oxygen saturation (SpO 2 ) was 99% at the end of the surgery. Ultrasound (US) showed no active bleeding in the needle track. The patient was sent to the observation room for rest and postoperative monitoring, and the patient’s family members were asked to press the puncture site for at least 30 min. A total of 30 minutes after surgery, the patient began to complain of pain with breathing in the puncture area; the US showed no obvious fluid accumulation around the puncture point or in the pelvic/abdominal cavity. HR was 70 beats per minute, BP was 103/72 mmHg, SpO 2 was 98%, and close observation was required. A total of 2 hours after surgery, the patient complained of discomfort in the right chest and abdomen, blood pressure dropped to 95/63 mmHg, HR was 68 beats per minute, and SpO 2 was 97%. Ultrasound revealed an effusion in the right thorax, but preoperative CT showed no fluid accumulation, so we strongly suspected that the puncture caused hemothorax (Fig.  2 ). Urgent blood routine examination showed red blood cell (RBC) level of 3.77 × 10 12 /L and hemoglobin (Hb) of 120 g/L. Dextrose saline infusion was administered to help increase the effective blood volume, stabilize the blood pressure, and replenish energy. At the same time, hemocoagulase was given immediately to stop bleeding. Considering the possibility of arterial bleeding, the patient was referred to the interventional department for digital subtraction angiography (DSA).

figure 1

A Liver biopsy route. B Biopsy tissue of liver obtained

figure 2

The US showed the right pleural effusion (white arrow), indicating the possibility of hemothorax

Transcatheter angiography was performed immediately in the interventional operating room. Using a right femoral artery approach, a 4-F SIM1 catheter (Clinical Supply, Hashima, Japan) was selected to perform the angiography of the right 8–12th intercostal artery and the right inferior phrenic artery, and there was no leak of contrast medium. Angiography of liver arteries showed accumulation of a small amount of contrast medium and embolization was performed with 150–360 μm gelfoam. However, the source of the hemothorax has not been found, and the patient’s blood pressure continued to drop, and with continuous dopamine pumping, the blood pressure could be forced to maintain at 70/40 mmHg. The patient’s unstable vital signs and the delayed identification of the bleeding source had posed significant challenges and immense pressure on both sides of the medical team. Consequently, we had made a collective decision to explore alternative blood vessels that might potentially be responsible for the hemorrhage. Finally, super-selective angiography of the right internal thoracic artery was performed using a microcatheter, which revealed significant contrast medium extravasation from the right musculophrenic artery (Fig.  3 ). Embolization was performed with approximately 1.5 ml of iodized oil (Lipiodol) mixed with N -butyl-2-cyanoacrylate (NBCA) (Lipiodol: NBCA, 4:1) and duplicated angiography showed successful embolization (Fig.  4 ). The vital signs of the patient were stabilized after the transarterial embolization (TAE) and supportive treatment.

figure 3

This showed contrast medium extravasation (white arrow) from the right musculophrenic artery, the terminal branch of the right internal thoracic artery

figure 4

Embolization was performed successfully and the bleeding was stopped

Reexamination of chest CT following TAE revealed a massive hemothorax on the right side, and a thoracic drain was inserted the next day (Fig.  5 ). A total of 2500 ml of bloody fluid was drained within 4 days. The biopsy pathology showed an advanced stage of primary biliary cirrhosis. The patient’s general condition stabilized, and then she was discharged on day 8 of hospitalization. The patient had a follow-up examination 3 months later, which showed no abnormalities in the abdominal and thoracic cavities, indicating satisfactory recovery.

figure 5

A Reexamination of chest computed tomography following transarterial embolization revealed a massive hemothorax on the right side. B A thoracic drain was inserted under ultrasound guidance

Discussion and conclusions

Liver biopsy is considered the most specific test for evaluating the etiology and severity of various hepatic disorders [ 2 ]. Percutaneous ultrasound-guided liver biopsy is currently the safest and most reliable method, and complications are infrequent, most of them being minor (pain and vasovagal reaction) [ 3 ]. Bleeding remains the most serious complication of liver biopsy, and massive bleeding can be life threatening [ 5 , 6 ]. Post-biopsy hemorrhage requiring intervention occurs in 0.4% of adults on average [ 7 , 8 , 9 ].

Hemorrhagic complications of liver biopsy include intrahepatic or subcapsular hematoma, intraperitoneal bleeding, hemobilia, and hemathorax [ 3 , 10 ]. Intrahepatic or subcapsular hematomas occur in 1–23% of cases and are usually small and asymptomatic, but larger hematomas may cause pain from stretching the liver capsule. Bleeding into the peritoneal cavity produces pain or hypotension [ 3 , 9 ]. For these two types of bleeding, ultrasound can display a color blood flow signal on the needle track and show intrahepatic or subcapsular liquid echo, or intraperitoneal blood accumulation. Most bleeding can be controlled by hemostatic treatment, absolute bed rest, and close monitoring of vital signs. In this case, when the patient complained of pain at the puncture site, we initially suspected intrahepatic or subcapsular hematoma caused by puncture needle track bleeding. However, ultrasound showed no positive signs and no fluid in the abdominal cavity, so this type of bleeding was ruled out. But angiography of liver arteries showed accumulation of contrast medium in the liver later and embolization was performed, which reminds us that even in the absence of ultrasound findings indicating liver or intraperitoneal bleeding, we should not take it lightly and the patient should be closely observed to prevent the possibility of delayed bleeding.

Hemothorax has been noted as a rare complication of percutaneous liver biopsy, and now with the guidance of ultrasound, the risk of hemothorax has been further reduced greatly, but it remains highly perilous and life threatening once it occurs [ 2 , 10 , 11 ]. Patients who develop hemothorax usually undergo biopsy of the right hepatic lobe via an intercostal approach, especially patients with liver cirrhosis and right liver atrophy, because the puncture needle needs to pass through the intercostal space, costophrenic angle, and the diaphragm, and possibly damage the blood vessels along the puncture path [ 12 ]. A few such cases have been reported, most cases are usually caused by injury to the intercostal artery or phrenic artery, and few are caused by damage to the lung tissue [ 4 , 9 , 10 , 13 , 14 , 15 , 16 ]. After the discovery of hemothorax in this case, we immediately considered the injury of the intercostal artery or the phrenic artery, but the angiography of the right 8–12th intercostal artery and the right inferior phrenic artery revealed no leak of contrast medium. However, at that time, the patient’s blood pressure continued to drop, which was difficult to maintain, indicating that the bleeding did not stop by itself, and the bleeding point should not be found. Then it occurred to us that there are three main groups of blood supplying arteries to the diaphragm, including the inferior phrenic artery (branch of the abdominal aorta), the musculophrenic artery (one of the terminal branches of the internal thoracic artery), and the superior phrenic artery (branch of the thoracic aorta), which form extensive collateral anastomosis in the diaphragm, of which the inferior phrenic artery is the main blood supplying vessel to the diaphragm. As reported in the current literature, the phrenic artery injury detected by angiography generally refers to the inferior phrenic artery. In some cases, it is impossible to distinguish which group of artery injured due to the use of thoracotomy for hemostasis [ 4 , 10 , 14 , 16 ]. Is it possible that the other two groups of vessels were involved in this case? So the catheter was put into the subclavian artery and superselective angiography of the right internal thoracic artery was performed, which revealed bleeding from one of its terminal branches, the musculophrenic artery. No previous case report of hemothorax caused by injury of the musculophrenic artery after liver biopsy, to our knowledge, has been reported.

This case draws attention to the musculophrenic artery as a potential source of hemorrhage after percutaneous liver biopsy. Once suspected of hemothorax, the ultrasound physician should seek assistance from the interventional department as soon as possible to locate the bleeding point and promptly treat it with embolization. Except for the most commonly injured intercostal arteries, it is also necessary to identify all possible blood supply arteries to the diaphragm. While searching for a bleeding point, only by complete mapping of all major arterial branches of the abdominal aorta and the thoracic aorta can successful interventional radiology be achieved. Awareness of thoracic and abdominal vascular anatomy and analyzing all the possible blood vessels that may be damaged during the procedure is crucial for ultrasound and interventional physicians.

Availability of data and materials

Not applicable.

Abbreviations

Digital subtraction angiography

Transarterial embolization

Alanine transaminase

Aspartate transaminase

Alkaline phosphatase

Gamma glutamyl transpeptidase

Anti-mitochondria antibody

Antinuclear autoantibodies

Computed tomography

Blood pressure

Pulse blood oxygen saturation

Red blood cells

N -Butyl-2-cyanoacrylate

Ren FY, Piao XX, Jin AL. Delayed hemorrhage from hepatic artery after ultrasound-guided percutaneous liver biopsy: a case report. World J Gastroenterol. 2006;12:4273–5.

Article   PubMed   PubMed Central   Google Scholar  

Khalifa A, Rockey DC. The utility of liver biopsy in 2020. Curr Opin Gastroenterol. 2020;36:184–91.

Sparchez Z. Complications after percutaneous liver biopsy in diffuse hepatopathies. Rom J Gastroenterol. 2005;14:379–84.

PubMed   Google Scholar  

Orlando G, Goffette P, Gravante G, Ciccarelli O, Lerut J. Successful treatment of haemothorax following percutaneous liver biopsy using interventional radiology: importance of arterial anatomical variations. Transpl Int. 2008;21:708–10.

Article   PubMed   Google Scholar  

Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. American Association for the study of Liver D. Liver Biopsy Hepatol. 2009;49:1017–44.

Google Scholar  

Potretzke TA, Saling LJ, Middleton WD, Robinson KA. Bleeding complications after percutaneous liver biopsy: do subcapsular lesions pose a higher risk? AJR Am J Roentgenol. 2018;211:204–10.

Atwell TD, Spanbauer JC, Mcmenomy BP, et al . The timing and presentation of major hemorrhage after 18,947 image-guided percutaneous biopsies. AJR Am J Roentgenol. 2015;205:190–5.

Atwell TD, Smith RL, Hesley GK, et al . Incidence of bleeding after 15,181 percutaneous biopsies and the role of aspirin. AJR Am J Roentgenol. 2010;194:784–9.

Boyum JH, Atwell TD, Schmit GD, et al . Incidence and risk factors for adverse events related to image-guided liver biopsy. Mayo Clin Proc. 2016;91:329–35.

Chahal PS, Ready J. Hemothorax after percutaneous liver biopsy: an unusual complication. Am J Gastroenterol. 2002;97:1068–9.

Firpi RJ, Soldevila-Pico C, Abdelmalek MF, Morelli G, Judah J, Nelson DR. Short recovery time after percutaneous liver biopsy: should we change our current practices? Clin Gastroenterol Hepatol. 2005;3:926–9.

Babb RR, Jackman RJ. Needle biopsy of the liver. A critique of four currently available methods. West J Med. 1989;150:39–42.

CAS   PubMed   PubMed Central   Google Scholar  

Lok KH, Au HD, Li KK. Tension hemothorax: a dreaded complication of percutaneous liver biopsy. Clin Gastroenterol Hepatol. 2010;8:A36.

Majid AA. Hemorrhage from the diaphragm: an unusual cause of hemothorax after percutaneous liver biopsy. Am J Gastroenterol. 1990;85:104–5.

CAS   PubMed   Google Scholar  

Diaz-Sanchez A, Beceiro-Pedreno I, Marin-Jimenez I. Education and imaging. Hepatobiliary and pancreatic: percutaneous liver biopsy complicated by hemothorax. J Gastroenterol Hepatol. 2007;22:135.

Article   CAS   PubMed   Google Scholar  

Filingeri V, Sforza D, Tisone G. Complications and risk factors of a large series of percutaneous liver biopsies in patients with liver transplantation or liver disease. Eur Rev Med Pharmacol Sci. 2015;19:1621–9.

Download references

Acknowledgements

Author information, authors and affiliations.

Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao, 266003, Shandong, China

Jing-ru Yang, Sai Wu, Xiao-juan Tian, Zhuo-xi Xue & Xiao-yan Niu

Department of Interventional Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, Shandong, China

You can also search for this author in PubMed   Google Scholar

Contributions

JY and XN conducted a clinical examination of the patient, evaluated their preoperative tests and carried out the biopsy procedure. ZX and XT assisted with surgical materials preparation and postoperative patient monitoring. JL performed the DSA and TAE procedures for the patient. XN and SW carried out the thoracic catheterization. JY contributed to the initial draft of the manuscript. All authors have reviewed and approved the final version.

Corresponding author

Correspondence to Xiao-yan Niu .

Ethics declarations

Ethics approval and consent to participate.

This article was approved by the Medical Ethics Committee of the Affiliated Hospital of Qingdao University. Ethical code is QYFY WZLL 2864.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Yang, Jr., Wu, S., Li, J. et al. Hemothorax caused by injury of musculophrenic artery after ultrasound-guided percutaneous liver biopsy: a case report. J Med Case Reports 18 , 303 (2024). https://doi.org/10.1186/s13256-024-04619-8

Download citation

Received : 12 February 2024

Accepted : 02 May 2024

Published : 26 June 2024

DOI : https://doi.org/10.1186/s13256-024-04619-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Musculophrenic artery
  • Percutaneous liver biopsy
  • Angiography

Journal of Medical Case Reports

ISSN: 1752-1947

  • Submission enquiries: Access here and click Contact Us
  • General enquiries: [email protected]

presentation in ultrasound report

United Nations Sustainable Development Logo

Media Advisory | Report launch: The Sustainable Development Goals Report 2024

presentation in ultrasound report

Report launch: The Sustainable Development Goals Report 2024

Live on WebTV  

The report is under embargo until 28 June 2024, 11:30 am EDT

With just six years remaining to the 2030 deadline, current progress falls far short of what is required to achieve the Sustainable Development Goals (SDGs) , according to The Sustainable Development Goals Report 2024 .

The report details the significant challenges the world is facing in making substantial strides towards achieving the SDGs. The report also highlights where action must accelerate, particularly in critical areas undermining SDG progress — climate change, peace and security, inequalities among and between countries, among others.

WHAT           Press briefing to launch The Sustainable Development Goals Report 2024

  • António Guterres , United Nations Secretary-General
  • Li Junhua , UN Under-Secretary-General for Economic and Social Affairs
  • Stefan Schweinfest , Director, Statistics Division, UN Department of Economic and Social Affairs, UN DESA
  • Yongyi Min , Chief, SDG Monitoring Section, Statistics Division, UN DESA

WHEN          Friday, 28 June 2024, 11:30 am EDT (following the noon briefing)

WHERE         UN Press Briefing Room, S-237 (Live on http://webtv.un.org )

For more information, please visit: https://unstats.un.org/sdgs/report/2024/ Hashtag: #SDGreport #SDGs #GlobalGoals

Media contacts:

Sharon Birch, UN Department of Global Communications, [email protected]

Helen Rosengren, UN Department of Economic and Social Affairs, [email protected]

The net-zero materials transition: Implications for global supply chains

Increasingly bold climate targets are changing global materials supply chains, to the extent that the transition to a net-zero emissions economy has sparked a “materials transition.” This report aims to provide an integrated perspective on these supply-chain changes, including materials demand, shortages that can be expected, and key actions that will be required to balance the equation and safeguard the speed of the transition.

About the authors

This article is a collaborative effort by Patricia Bingoto, Michel Foucart, Maria Gusakova , Thomas Hundertmark , and Michel Van Hoey , representing views from McKinsey’s Materials Practice.

With these points in mind, our research explores the following key findings:

Materials are a critical enabler of the net-zero transition. The world has embarked on an ambitious decarbonization journey toward a net-zero emissions economy, which will require fundamental technology shifts across industries at an unprecedented speed. These technologies often require more physical materials for the same output when compared with their conventional counterparts during the construction phase. For example, battery electric vehicles (BEVs) are typically 15 to 20 percent heavier than comparable internal-combustion engine (ICE) vehicles and will therefore become a key driver for materials demand in the coming decades. Consequently, the extent to which global materials supply chains can keep up with new and accelerating sources of demand will be a critical determinant of global decarbonization rates.

Even with the current decarbonization trajectory trending toward 2.4° Celsius, the supply of many minerals and metals embedded in key lower-carbon technologies will face a shortage by 2030. While some materials such as nickel may experience modest shortages (approximately 10 to 20 percent), others such as dysprosium, which is magnetic material used in most electric motors, could see shortages of up to 70 percent of demand. Unless mitigation actions are put in place, such shortages would likely hinder the global speed of decarbonization because customers would be unable to shift to lower-carbon alternatives. Moreover, these shortages would lead to price spikes and volatility across materials, which in turn would make the technologies in which they are embedded more expensive and further slow adoption rates.

We will continue to see a high concentration of mineral and metals supplies in a handful of countries, including for example China (rare-earth elements), the Democratic Republic of the Congo (cobalt), and Indonesia (nickel). Combined with a regulatory landscape that is increasingly focused on regionalization—as seen through the US Inflation Reduction Act and the EU Green Deal Industrial Plan, for example—these concentrated supplies could affect regional access to materials within the scope of certain agreement areas, even when the global market is balanced. At the same time, such concentration could also offer opportunities to traditional mining countries to develop refining activities domestically.

Harmonized actions on supply, demand, innovation, and policy will be required to balance the equation and safeguard the speed of the transition.

  • Supply. It is crucial to ensure the timely scale-up of projects that have already been announced, which will require mining to accelerate beyond historical growth rates for many materials while simultaneously doubling down on exploration to ensure further scale-up of supply beyond 2030. Investments in mining, refining, and smelting will need to increase to approximately $3 trillion to $4 trillion by 2030 (about $300 billion to $400 billion per year). 1 This represents a 50 percent increase compared to the previous decade, in a context where mining investments have been declining in the recent past (approximately $260 billion in 2012 to approximately $150 billion in 2019, a decline of about 40 percent). Moreover, capital will need to be redirected toward new materials, with stable investments in iron ore but twice the investments in copper and an eightfold increase in investments in lithium expected. Labor capacity will need to be increased by 300,000 to 600,000 specialized mining professionals, and an additional 200 to 500 gigawatts of (ideally low-carbon) energy will need to come online by 2030 to power these assets, equivalent to 5 to 10 percent of estimated solar and wind power capacity by 2030. Finally, the scale-up will require smooth permitting processes, timely infrastructure deployment, equipment availability, and adequate water resources.
  • Demand. Downstream industries will need to shift demand patterns toward proven technologies that are less materials-intensive or that require different materials for which supply is less constrained.
  • Innovation. Investments in materials innovation and breakthrough technologies should be amplified. On the demand side, this might involve exploring material substitution options for long-term-constrained or regionally concentrated materials. On the supply side, investors could consider focusing on enhanced recycling practices for new materials such as rare-earth minerals, as well as innovative solutions to increase the throughput of existing assets.
  • Policy. New policies may facilitate the scale-up of supply, such as by streamlining permitting procedures for new asset developments. Policies could also enable a demand shift toward alternative technologies by guaranteeing a level playing field across different technological options, for example, and safeguarding regional security of supply and industry competitiveness.

Stakeholders can increase the likelihood of success by developing strategies that offer optionality and resilience across a broad range of global responses to material shortages. As a first step toward mitigating risk and tapping into the vast opportunities presented by the materials transition, it will be critical for governments and companies alike to maintain or strengthen their understanding of the dynamics of the global materials supply chain and potential long-term scenarios. For governments, doing so could help shine a light on the security of supply and safeguard the long-term competitiveness of local industries. For companies, it can inform decisive actions that are more likely to position them as industry leaders in the years to come.

As the world accelerates the deployment of climate technologies in support of the net-zero transition, there is a risk that materials supply might not scale at the required speed. Our research has shown that energy and materials are strongly interconnected and that the world will also have to go through a materials transition to deliver on its net-zero ambitions.

While several uncertainties remain about how the materials transition will play out—such as the speed of decarbonization, development of trade policies, speed of innovation and time to market for breakthrough technologies, and permitting timelines for new projects, among others—governments and companies can plan strategic actions that are resilient across a broad range of outcomes.

As a first step toward mitigating risks and tapping into the vast opportunities presented by the materials transition, it is critical for governments and companies to maintain or strengthen their understanding of changing global materials supply chain dynamics with a long-term perspective. For governments, doing so could help shine a light on security of supply and safeguarding long-term competitiveness of local industries. And similar to the actions and results of frontrunners in the energy transition, companies can gain insight on decisive actions that are more likely to position them as industry leaders in the years to come.

Patricia Bingoto is a senior expert in McKinsey’s Zurich office; Michel Foucart is an associate partner in the Brussels office; Maria Gusakova is a partner in the Houston office, where Thomas Hundertmark is a senior partner; and Michel Van Hoey is a senior partner in the Luxembourg office.

The authors wish to thank Elaine Almeida, Marcelo Azevedo, Hana Dadic, Max Derie, Karel Eloot, Karilyn Farmer, Nicolas Goffaux, Ilana Kochetkova, Gregory Kudar, Laura Latzel, Sigurd Mareels, Amélie Nicolay, Nathan Reinders, Alina Saranova, Bram Smeets, Cécilia Smissaert, Sven Smit, Michelle Stitz, Humayun Tai, Iris Tavernier, Frederik Wullepit, Corinne Yabroudi, and Inese Zepa for their contributions to this report.

Explore a career with us

Related articles.

Rolled metal warehouse. Many packs of metal bars on the shelves

How a ‘materials transition’ can support the net-zero agenda

You are using an outdated browser. Please upgrade your browser or activate Google Chrome Frame to improve your experience.

ISUOG Logo

  • You're here:
  • Clinical resources
  • Resource Library search

Lecture 25: Gynecological ultrasound: the basics

This lecture was delivered by Dr Shabnam Bobdiwala at ISUOG's Basic Training Programme in Singapore, in October 2018.

Download the presentation to support your learning: Gynecological ultrasound: the basics 

Creative Communications

ISUOG Basic Training by ISUOG is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License . Based on a work at https://www.isuog.org/education/basic-training.html . Permissions beyond the scope of this license may be available at https://www.isuog.org/

Shabnam Bobdiwala.png

IMAGES

  1. PPT

    presentation in ultrasound report

  2. The 10 Clinical Guidelines for the Perfect Ultrasound Report Format

    presentation in ultrasound report

  3. Routine first-trimester ultrasound screening using a standardized

    presentation in ultrasound report

  4. PPT

    presentation in ultrasound report

  5. OB ultrasound report template in Word and Pdf formats

    presentation in ultrasound report

  6. Report Writing in Ultrasound

    presentation in ultrasound report

VIDEO

  1. Ultrasound Report of endometrial polyp. Sonography of Endometrial mass/polyp

  2. Variable Presentation In Pregnancy Ultrasound

  3. FMU Case presentation on Placenta Abruptio -Dr S Marangwanda and Report Writing

  4. UE Systems Ultrasound World Presentation

  5. Ultrasound of a ruptured infraspinatus with associated posterior GHJ Effusion

  6. Baby at 13 weeks

COMMENTS

  1. The clinical ultrasound report: Guideline for sonographers

    Given the acute presentation with pain and jaundice combined with the presence of gallstones in the gallbladder, choledocholithiasis is considered highly likely. The pancreas was well visualized and appears normal. ... An ultrasound report is a formal document and represents an important waypoint on the management pathway of the patient.

  2. Sonography Fetal Assessment, Protocols, and Interpretation

    Fetal ultrasonography is an essential element in the evaluation of anomalies and fetal well-being throughout pregnancy. The increasing incidence of morbid obesity, hypertension, and gestational diabetes within the reproductive age group places this high-risk population at increased adverse fetal events such as stillbirth and fetal anomalies. In every trimester, there are specific maternal and ...

  3. Variation in fetal presentation

    There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os. This includes: cephalic presentation: fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations ...

  4. PDF Chapter 15 WRITING THE ULTRASOUND REPORT

    The ultrasound report becomes part of the patient's medical record and is a permanent documentation of the ultrasound examination. National and international ultrasound ... amniotic fluid and the presentation and lie of the fetus. Fetal biometric measurements should include the gestational sac if an embryo is not visualized, a crownrump ...

  5. ISUOG Practice Guidelines: performance of third-trimester obstetric

    Jan 4, 2024 Practice Guidelines. This document outlines recommended guidelines for conducting third-trimester ultrasound examination, encompassing determination of placental location and fetal presentation, measurement of fetal biometry, identification of fetal anomalies, evaluation of amniotic fluid volume and documentation of fetal and ...

  6. How to Read a Pregnancy Ultrasound Report

    There are two main types of ultrasound procedures done during pregnancy: Transabdominal scan (TAS): A sonographer will squeeze gel onto your belly and then run the transducer over the surface of your skin to capture the fetal anatomy of your growing baby. Transvaginal scan (TVS): A sonographer will insert a lubricated wand into your vagina to ...

  7. What makes a good ultrasound report?

    The report is the primary means of communication between the ultrasound department and the referring clinician. It constitutes a clinical opinion and provides a specialist interpretation of images. 2 It should be accurate and inform patient management. 3. Reports comprise part of the permanent record held in the patient's notes and thus are ...

  8. PDF O-RADS US v2022 HOW TO REPORT: ESSENTIAL COMPONENTS and LEXICON

    sections of a pelvic ultrasound exam report utilizing O-RADS US v2022 to describe the adnexa and relevant features for scoring. Examples for single and multiple lesions are presented in prose and list formats to demonstrate different reporting styles. Sample 1 (prose: physiologic cyst - corpus luteum) ...

  9. Lecture 25g: Writing the gynecological ultrasound report

    Lecture 25g: Writing the gynecological ultrasound report. This lecture was delivered by Dr Shabnam Bobdiwala at ISUOG's Basic Training Course in gynecology, in partnership with Erasmus Medical Center in Rotterdam, in 2018. 763C7E64-F09C-4F59-ACEEBB0934DFD169. Feel free to download this presentation to support your learning.

  10. PDF ISUOG Basic Training

    ISUOG Basic Training. Writing the Gynecological Ultrasound Report. Basic Training. At the end of the lecture you will be able to: • Write a clear, concise and accurate gynecology ultrasound report • Understanding the importance of writing a good gynecology ultrasound report • Understand the basic principles of gynecology ultrasound reporting.

  11. PDF ULTRASOUND EXAMINATION IN PREGNANCY

    The main objective of a second trimester fetal ultrasound scan is to provide accurate diagnostic information on the presence or absence of fetal anomalies. It is recommended that a second-trimester ultrasound scan be performed between 18 and 22 weeks of gestation. Storage of motion video-clips are recommended for the fetal heart assessment.

  12. Evaluation and Referral for Developmental Dysplasia of the Hip in

    Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and ...

  13. Screening for breech presentation using universal late-pregnancy

    The incidence of breech presentation at term is around 3%-4% [1-3], and fewer than 10% of foetuses who are breech at term revert spontaneously to a vertex presentation . Although breech presentation is easy to detect through ultrasound screening, many women go into labour with an undetected breech presentation . The majority of these women ...

  14. The 10 Clinical Guidelines for the Perfect Ultrasound Report Format

    3. Ultrasound Imaging Technique. The ultrasound technique used (2D, 3D, Doppler, etc.) should be clearly stated. Different techniques provide varying levels of detail and functionality. Specifying the technique ensures that the interpreting physician understands the nature of the images presented. 4.

  15. Impact of point-of-care ultrasound and routine third trimester ...

    The role of a routine third ultrasound assessment of fetal presentation has been reported but the impact on neonatal outcomes is yet to be determined. There are limited reports on antenatal use of handheld point-of-care ultrasound (POCUS) for the determination of fetal presentation, but the impact of their systematic use for this purpose is ...

  16. PDF Training in Diagnostic Ultrasound: Essentials, Principles and Standards

    Contents 1. lntroduction 1.1 Background to the Study Group's report 1.2 Structure of the report 2. The world situation with respect to ultrasonography 2.1 Assessment of current practice 2.1 .l Performance and interpretation 2.1.2 Delivery of services 2.1.3 Equipment and techniques 2.1.4 Recognized indications for ultrasonography 2.2 Trends in ultrasonography

  17. Case Reports

    5. An unexpected association between diseases or symptoms. 6. An unexpected event in the course of observing or treating a patient. 7. Findings that shed new light on the possible pathogenesis of a disease or an adverse effect. Case reports should include an up-to-date review of all previous cases in the field.

  18. Report Writing in Ultrasound

    REPORT WRITING IN ULTRASOUND - Free download as Powerpoint Presentation (.ppt / .pptx), PDF File (.pdf), Text File (.txt) or view presentation slides online. This document provides guidelines for ultrasound report writing. It discusses that ultrasound reports are an important form of communication between sonographers and referring clinicians and influence patient management.

  19. A 42-year-old woman with abnormal uterine bleeding—leiomyoma (AUB-L

    Transabdominal pelvic ultrasound revealed a lower uterine segment/cervical fibroid measuring 7.5 × 5 × 7.8 cm (length × depth × width). ... We report the case of a 42-year-old Asian American woman who presented to the emergency department with chronic abnormal uterine bleeding and symptoms of anemia, including multiple syncopal episodes and ...

  20. Identification of breech presentation

    Only the probabilistic results (n=100000 simulations) were reported which showed that on average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39% compared with selective ultrasound scanning. The expected cost per person with breech presentation of universal ultrasound was £2957 (95% Credibility Interval [CrI ...

  21. 2024 Trafficking in Persons Report

    The 2022 UNODC Global Report on Trafficking in Persons noted trafficking in persons for the purpose of organ removal constituted only 0.2 percent of detected victims of trafficking compared to the much higher numbers for sex trafficking and forced labor. UNODC has warned "existing barriers to reporting suggest that the full scale of this ...

  22. Hemothorax caused by injury of musculophrenic artery after ultrasound

    Percutaneous ultrasound-guided liver biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases [].Hemorrhage is the most common major complication after liver biopsy, and bleeding of any kind has been reported to occur in up to 11% of patients [].Hemothorax is much less common than other types of hemorrhage and can be very dangerous and life-threatening [].

  23. Lecture 30: Writing the gynecological ultrasound report

    This lecture was delivered by Dr Mala Sibal at ISUOG's Basic Training Course in Chennai, in September 2018. Download the presentation to support your learning: Writing the gynecological ultrasound report. ISUOG Basic Training by ISUOG is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Based ...

  24. PDF GUIDELINES

    ultrasound at the 11 to 13+6-week fetal ultrasound examination1. When performing Doppler imaging, the displayed thermal index (TI) should be ≤ 1.0 and expo-sure time should be kept as short as possible, usually no longer than 5-10 min and not exceeding 60 min1. It is not the intention of these Guidelines to define

  25. Webinar: Emerging trends to watch in 2024

    Recently, experts from Lawrence Livermore National Laboratory, The Ohio State University, Oak Ridge National Laboratory, and CAS joined together for a webinar on January 25 to highlight the scientific breakthroughs and trends to watch in 2024. Discover the latest developments on tackling the undruggable, AI's impact in R&D, the rise of ...

  26. World Drug Day report highlights spike in drug use, increased

    The hope for World Drug Day. The UNODC report highlights that the "right to health is an internationally recognized human right that belongs to all human beings, regardless of a person's drug use status or whether a person is imprisoned, detained or incarcerated". UNODC's calls for governments, organizations and communities to collaborate on establishing evidence-based plans that will ...

  27. Media Advisory

    Report launch: The Sustainable Development Goals Report 2024 Live on WebTV The report is under embargo until 27 June 2024, 12:30 pm EDT With just six years remaining to the 2030 deadline, current ...

  28. How the energy transition could affect material supply chains

    Increasingly bold climate targets are changing global materials supply chains, to the extent that the transition to a net-zero emissions economy has sparked a "materials transition." This report aims to provide an integrated perspective on these supply-chain changes, including materials demand, shortages that can be expected, and key actions that will be required to balance the equation ...

  29. Lecture 25: Gynecological ultrasound: the basics

    Download the presentation to support your learning: Gynecological ultrasound: the basics . ... International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) 122 Freston Road, London W10 6TR, UK Tel: +44 (0) 20 7471 9955 / Fax: +44 (0) 20 7471 9959 Email: [email protected]