Uncertainty-Calibrated Explainable Artificial Intelligence for Fetal Ultrasound Plane Classification: A Systematic Review

Abstract

Fetal ultrasound is the cornerstone of antenatal care, and accurate recognition of a small set of standard anatomical planes underpins biometry, growth surveillance, and detection of structural anomalies. Deep learning classifiers now match or exceed expert accuracy on curated benchmarks, but most remain opaque and miscalibrated, leaving clinicians without the calibrated confidence or faithful explanations needed for safe decision support. We systematically reviewed 78 studies published between January 1, 2015 and April 30, 2026 that paired automated fetal plane classification with explainability or predictive uncertainty quantification, following PRISMA 2020. Pooled balanced accuracy across six standard planes was 0.93 (95% CI 0.91 to 0.95), but only 19 studies (24%) reported calibration and 14 (18%) reported selective prediction. We propose CALIB-XFUS, a 22-item reporting framework that operationalises calibration, explanation faithfulness, and fairness for regulated fetal ultrasound artificial intelligence. The framework spans six domains: clinical task and indication for use; dataset provenance and representativeness; model and training pipeline; calibration and selective prediction; explanation faithfulness and clinician validation; and post-market surveillance. We argue that uncertainty-calibrated, faithfully explained, and fairness-audited fetal ultrasound AI is now both technically feasible and regulatorily expected under the FDA Good Machine Learning Practice principles and the EU AI Act high-risk obligations.