Abstract
BackgroundThe importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making.MethodsThe study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants’ ability to distinguish high and low risk cases and personal decision thresholds.ResultsWhen reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians.ConclusionsCurrently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making.
Highlights
The importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries
Currently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines
This study examined one such situation, the decision to transfer a woman in labour from a community maternity unit to a specialist obstetric unit; a decision which is central to the provision of high quality, safe maternity care in rural areas
Summary
The importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. Where local maternity services are not provided women living in remote areas may be required to travel long distances to urban centres to await birth [4,5] These women may experience increased rates of induction of labour, emotional distress due to separation from family and community, and family financial hardship [5,6,7]. There are continuing concerns about maintenance of skills of rural clinicians and about the safety of mothers and babies where unanticipated problems arise during labour in rural areas [9]
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