Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

Association of personal and systemic factors on intrapartum risk perception and obstetric intervention rates: a cross-sectional study

BACKGROUND

Risk perception is fundamental to decision-making; therefore its exploration is essential to gaining a comprehensive understanding of the decision-making process for peripartum interventions. The aim of this study was to investigate associations between personal and systemic factors of the work setting and the risk perception of obstetric healthcare professionals, and in turn how this might influence decisions regarding obstetric interventions.

METHODS

Case vignettes were used to measure risk perception. A quantitative cross-sectional online survey was performed within an exploratory sequential mixed-methods design, and an intervention readiness score created. Associations were calculated using location and dispersion measures, t-tests and correlations in addition to multiple linear regression.

RESULTS

Risk perception, as measured by the risk assessment score, was significantly lower (average 0.8 points) for midwives than for obstetricians (95%-CI [-0.673; -0.317], p < .001). Statistically significant correlations were found for: years of experience and annual number of births in the current workplace, but this was not clinically relevant; hours worked, with the groups of participants working ≥ 30,5 h showing a statistically significant higher risk perception than participants working 20,5-30 h (p = .005); and level of care of the current workplace, with the groups of participants working in a birth clinic (Level IV) showing a statistically significant lower risk perception than participants working in Level I hospital (highly specialised obstetric and neonatal care; p = .016). The option of midwife-led birthing care showed no correlation with risk perception. The survey identified that risk perception, occupation, years in the profession and number of hours worked (i.e. full or part time) represent significant influences on obstetric healthcare professionals' willingness to intervene.

CONCLUSIONS

The results of the survey give rise to the hypothesis that the personal and systemic factors of professional qualification, occupation, number of hours worked and level of acuity of the workplace are related to the risk perception of obstetric healthcare professionals. In turn, risk perception itself made a significant contribution to explaining differences in willingness to intervene, suggesting that it influences obstetricians' and midwives' decision-making. Overall, however, the correlations were weak and should be interpreted cautiously. The significant variations in the use of interventions must be addressed in order to provide the highest quality and best possible care for childbearing women and their families. To this end, developing strategies to improve interdisciplinary relationships and collaboration is of great importance.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017172 (18.06.2019).

Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes

BACKGROUND

Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes.

METHODS

In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics.

FINDINGS

The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed.

CONCLUSION

Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

Intrapartum risk perception-A qualitative exploration of factors affecting the risk perception of midwives and obstetricians in the clinical setting

OBJECTIVE

to gain an in-depth view of the specific risk perception of midwives and obstetricians, in order to achieve a deeper understanding of the situations which midwives and obstetricians perceive as risky and of the factors affecting their risk perception.

DESIGN

a qualitative approach using focus group discussions was used as part of the first strand within a sequential explorative mixed methods project.

PARTICIPANTS

24 midwives and obstetricians providing labour care in the clinical setting ANALYSIS: according to qualitative content analysis.

FINDINGS

both external and internal factors were identified which potentially influence the risk perception of midwives and obstetricians: (i) the individual perception of the obstetric health professional, (ii) the dyad of obstetric health professional & woman, (iii) being part of a team and (iv) being part of an institution. While risk definitions/classifications and obstetric risk factors were less common topics, structural and organisational factors, such as lack of staff and excessive workload, dominated the discussions about risky situations in the delivery room.

KEY CONCLUSION

Obstetric health professionals' risk perception is multifactorial and risky situations in the delivery room can be described as a complex construct of various factors. The results suggest that there are different forms of risk perception and different factors which are perceived as risky.

IMPLICATIONS FOR PRACTICE

Reflection on one's own role and actions should be included in the training of obstetric professionals and also be maintained in everyday professional life.

Expert and novice sensitivity to environmental regularities in predicting NFL games

We study whether experts and novices differ in the way they make predictions about National Football League games. In particular, we measure to what extent their predictions are consistent with five environmental regularities that could support decision making based on heuristics. These regularities involve the home team winning more often, the team with the better win-loss record winning more often, the team favored by the majority of media experts winning more often, and two others related to surprise wins and losses in the teams’ previous game. Using signal detection theory and hierarchical Bayesian analysis, we show that expert predictions for the 2017 National Football League (NFL) season generally follow these regularities in a near optimal way, but novice predictions do not. These results support the idea that using heuristics adapted to the decision environment can support accurate predictions and be an indicator of expertise.

A Test-Retest Reliability Generalization Meta-Analysis of Judgments Via the Policy-Capturing Technique

Policy capturing is a widely used technique, but the temporal stability of policy-capturing judgments has long been a cause for concern. This article emphasizes the importance of reporting reliability, and in particular test-retest reliability, estimates in policy-capturing studies. We found that only 164 of 955 policy-capturing studies (i.e., 17.17%) reported a test-retest reliability estimate. We then conducted a reliability generalization meta-analysis on policy-capturing studies that did report test-retest reliability estimates—and we obtained an average reliability estimate of .78. We additionally examined 16 potential methodological and substantive antecedents to test-retest reliability (equivalent to moderators in validity generalization studies). We found that test-retest reliability was robust to variation in 14 of the 16 factors examined but that reliability was higher in paper-and-pencil studies than in web-based studies and was higher for behavioral intention judgments than for other (e.g., attitudinal and perceptual) judgments. We provide an agenda for future research. Finally, we provide several best-practice recommendations for researchers (and journal reviewers) with regard to (a) reporting test-retest reliability, (b) designing policy-capturing studies for appropriate reportage, and (c) properly interpreting test-retest reliability in policy-capturing studies.

Scoping review of the impact of birth trauma on clinical decisions of midwives

OBJECTIVE

The psychological and emotional impact of a traumatic birth experience on clinicians is well-established. It is also known that emotions can generally influence decisions. However, it is not clear whether experiencing a birth trauma can affect the professional behaviour and decision-making of clinicians. This study explores the impact of birth trauma on clinical decision-making of midwives.

DATA SOURCES

Four databases (Medline, Scopus, CINAHL and ProQuest) were searched to identify English language studies published from 1990 to 2018. Due to the lack of studies with specific focus on clinical decision-making after birth trauma, we defined two main domains for our literature search. To be included, studies had to focus on either traumatic birth experience or clinical decision-making in midwifery. The findings of the two domains were then integrated.

STUDY SELECTION

Of a total 2104 studies identified, 70 received full-text screening with 40 included in the review. Twenty-two articles were about traumatic birth events and 18 examined decision-making in midwifery.

DATA EXTRACTION

Information were extracted on each article's purpose, study design, data collection, participants, definitions of birth trauma and the context in which clinical decisions were made.

RESULTS

Thematic analysis was conducted. The impact of birth trauma on midwives could be categorized into the following themes: psychological issues; professional concerns; changes in practice and positive impact. Review of literature indicated that clinical decision-making could be influenced through all these themes.

CONCLUSION

Decision-making can be impacted by the midwife's affective state related to previous experience of birth trauma. The continuum of impact may vary from increased defensiveness to increased personal and professional growth. Being aware of this impact can help midwives to better manage their emotions while making decision after traumatic birth experiences.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Pregnancy related risk perception in pregnant women, midwives & doctors: a cross-sectional survey

Background

Risk perception in relation to pregnancy and birth is a complex process influenced by multiple personal, psychological and societal factors. Traditionally, the risk perception of healthcare professionals has been presented as more objective and authoritative than that of pregnant women. Doctors have been presented as more concerned with biomedical risk than midwives. Such dichotomies oversimplify and obscure the complexity of the process. This study examines pregnancy-related risk perception in women and healthcare professionals, and what women and professionals believe about each other’s risk perception.

Methods

A cross sectional survey of set in UK maternity services. Participants were doctors working in obstetrics (N = 53), midwives (N = 59), pregnant women (N = 68). Participants were recruited in person from two hospitals. Doctors were also recruited online. Participants completed a questionnaire measuring the degree of perceived risk in various childbirth-related scenarios; and the extent to which they believed others agreed with them about the degree of risk generally involved in childbirth. Main outcome measures were the degree of risk perceived to the mother in baby in pregnancy scenarios, and beliefs about own perception of risk in comparison to their own group and other groups.

Results

There were significant differences in total risk scores between pregnant women, doctors and midwives in perception of risk to the mother in 68/80 scenarios. Doctors most frequently rated risks lowest. Total scores for perceived risk to the baby were not significantly different. There was substantial variation within each group. There was more agreement on the ranking of scenarios according to risk. Each group believed doctors perceived most risk whereas actually doctors most frequently rated risks lowest. Each group incorrectly believed their peers rated risk similarly to themselves.

Conclusions

Individuals cannot assume others share their perception of risk or that they make correct assessments regarding others’ risk perception. Further research should consider what factors are taken into account when making risk assessments,

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2467-4) contains supplementary material, which is available to authorized users.

Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study

BACKGROUND

Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear.

AIM

To study the significance of relationships in rural midwifery and provide insights to inform midwifery education.

METHODS/DESIGN

Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data.

FINDINGS

Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships.

CONCLUSIONS

To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice.

IMPLICATIONS

Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.

'Living the rural experience-preparation for practice': The future proofing of sustainable rural midwifery practice through midwifery education

Rural practice presents unique challenges and skill requirements for midwives. New Zealand and Scotland face similar challenges in sustaining a rural midwifery workforce. This paper draws from an international multi-centre study exploring rural midwifery to focus on the education needs of student midwives within pre-registration midwifery programmes in order to determine appropriate preparation for rural practice. The mixed-methods study was conducted with 222 midwives working in rural areas in New Zealand (n = 145) and Scotland (n = 77). Midwives' views were gathered through an anonymous online survey and online discussion forums. Descriptive analysis was used for quantitative data and thematic analysis was conducted with qualitative data. 'Future proofing rural midwifery practice' using education was identified as the overarching central theme in ensuring the sustainability of rural midwives, with two associated principle themes emerging (i) 'preparation for rural practice' and (ii) 'living the experience and seeing the reality'. The majority of participants agreed that pre-registration midwifery programmes should include a rural placement for students and rural-specific education with educational input from rural midwives. This study provides insight into how best to prepare midwives for rural practice within pre-registration midwifery education, in order to meet the needs of midwives and families in the rural context.

Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009

BACKGROUND

Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women.

METHODS

Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors.

RESULTS

Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies.

CONCLUSION

Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland

OBJECTIVE

the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice.

DESIGN

online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis.

SETTING AND PARTICIPANTS

222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland.

FINDINGS

underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities.

KEY CONCLUSIONS

rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth.

IMPLICATIONS FOR PRACTICE

findings will inform the preparation of midwives for rural midwifery practice.

Factors influencing the clinical decision-making of midwives: a qualitative study

Background

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives’ decisions are based on more than the evidence based medicine (EBM) model – i.e. clinical evidence, midwife’s expertise, and woman’s values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently.

Methods

We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives’ clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts.

Results

We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives’ clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged.

Conclusion

Midwives’ clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

Interhospital Transfer of Children in Septic Shock: A Clinician Interview Qualitative Study

OBJECTIVE:

To determine the factors that influence the decision to transfer children in septic shock from level II to level I pediatric intensive care unit (PICU) care.

DESIGN:

Interviews with level II PICU physicians in Michigan and Northwest Ohio. A hypothetical scenario of a 14-year-old boy in septic shock was presented.

BASELINE:

40 mL/kg fluid resuscitation, central venous and peripheral arterial access, and high-dose vasopressor infusions were provided.

ESCALATION POINT:

After 2 hours. When the patient is in catecholamine-resistant shock and oliguric, invasive mechanical ventilation is initiated.

MEASUREMENTS AND MAIN RESULTS:

All 19 eligible physicians participated. At baseline, respondents would assess measures of perfusion and hemodynamics: blood pressure (BP; 15 [79%]), lactate (12 [63%]), and central venous oxygen saturation (ScvO₂; 10 [53%]). Poor clinical response was signified by low BP (11 [58%]), elevated lactate (9 [47%]), low urine output (8 [42%]), and low ScvO₂ (6 [32%]). At the escalation point, 13 of 18 respondents felt there was <50% probability of clinical turnaround without escalating treatment, though only 3 (16%) would call to discuss transfer. Seven (37%) respondents would give more fluid, whereas 8 (42%) would use central venous pressure to guide fluid resuscitation. Ultimately, 15 (79%) respondents would transfer for extracorporeal membrane oxygenation (ECMO) or renal replacement therapy if there was no response to escalated care. Four (21%) respondents would not transfer the patient: 1 felt appropriate care could be provided in the level II PICU, 2 felt transfer was unconventional, and 1 was unaware ECMO could be provided in refractory septic shock.

CONCLUSIONS:

Level II to level I PICU transfer of children with septic shock is triggered by perceived nonresponse to locally available therapies. Few referring physicians do not transfer children in refractory septic shock. This study provides new insight into decision-making that influences the interhospital transfer of children with septic shock.

Open, trusting relationships underpin safety in rural maternity a hermeneutic phenomenology study

BACKGROUND

There are interwoven personal, professional and organisational relationships to be navigated in maternity in all regions. In rural regions relationships are integral to safe maternity care. Yet there is a paucity of research on how relationships influence safety and nurture satisfying experiences for rural maternity care providers and mothers and families in these regions. This paper draws attention to how these relationships matter.

METHODS

This research is informed by hermeneutic phenomenology drawing on Heidegger and Gadamer. Thirteen participants were recruited via purposeful sampling and asked to share their experiences of rural maternity care in recorded unstructured in-depth interviews. Participants were women and health care providers living and working in rural regions. Recordings were transcribed and data interpretively analysed until a plausible and trustworthy thematic pattern emerged.

RESULTS

Throughout the data the relational nature of rural living surfaced as an interweaving tapestry of connectivity. Relationships in rural maternity are revealed in myriad ways: for some optimal relationships, for others feeling isolated, living with discord and professional disharmony. Professional misunderstandings undermine relationships. Rural maternity can become unsustainable and unsettling when relationships break down leading to unsafeness.

CONCLUSIONS

This study reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care. Relationships are founded on mutual understanding and attuned to trust matter. These relationships are forged over time and keep childbirth safe and enable maternity care providers to work sustainably. Yet hidden unspoken pre-understandings of individuals and groups build tension in relationships leading to discord. Trust builds healthy rural communities of practice within which everyone can flourish, feel accepted, supported and safe. This is facilitated by collaborative learning activities and open respectful communication founded on what matters most (safe positive childbirth) whilst appreciating and acknowledging professional and personal differences.

What is normal progress in the first stage of labour? A vignette study of similarities and differences between midwives and obstetricians

OBJECTIVE

intrapartum referrals are high-risk situations. To ensure patient safety, care professionals need to have a shared understanding of a labouring woman's situation. We aimed to gain insight into similarities and differences between midwives and obstetricians in the assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting in the Netherlands.

DESIGN

factorial survey.

SETTING

in the Netherlands, the main caregivers for women with low risks of pathology are primary-care midwives working in the locality. Approximately half of all women start labour under supervision of primary-care midwives. Roughly 40% of these women are referred to a hospital during labour, where obstetricians take over responsibility. In 2013, the reason for referral for 5161 women (14.1% of all referrals during labour) was a prolonged first stage of labour.

PARTICIPANTS

respondents consisted of primary-care midwives (N=69), obstetricians (N=47) and hospital based midwives, known as clinical midwives (N=31).

MEASUREMENTS

each respondent assessed seven hypothetical vignettes. The assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting based on this indication were used as outcome measures, rated on a 7-point Likert scale (1=very unlikely to 7=very likely). Data were analysed using a linear multilevel model with a two-level hierarchy.

FINDINGS

compared to primary-care midwives, obstetricians were more likely to define a prolonged first stage of labour when progress in cervical dilation was slow (b: 1.11; 95% CI: 0.66 - 1.57). The attributes parity, progress, intensity of uterine contractions and the woman's state of mind, were used by all three groups in the decision to refer a woman to clinical setting based on a prolonged first stage of labour. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: we found relevant interprofessional differences and similarities in the assessment of a prolonged first stage of labour and consequent referral. Further interprofessional alignment of clinical assessments, for instance through interprofessional discussions and a review of professional guidelines, might help to improve collaborative care.

The closure of rural and remote maternity services: Where are the midwives?

Decisions to close small maternity units in rural and remote communities have often precipitated a community response as women and families rally to save local services. But where are the midwives? We argue here that professional bodies such as colleges of midwives have a responsibility to advocate more strongly at a political level for evidence-based decisionmaking regarding the allocation of rural services. We suggest that adopting a comprehensive definition of maternity services risk that considers both social and health services risks and their impact on clinical risk, could provide a solid basis for effective advocacy by professional bodies.

The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth

Background

Evidence from the Birthplace in England Research Programme supported a policy of offering ‘low risk’ women a choice of birth setting, but a number of unanswered questions remained.

Aims

This project aimed to provide further evidence to support the development and delivery of maternity services and inform women’s choice of birth setting: specifically, to explore maternal and organisational factors associated with intervention, transfer and other outcomes in each birth setting in ‘low risk’ and ‘higher risk’ women.

Design

Five component studies using secondary analysis of the Birthplace prospective cohort study (studies 2–5) and ecological analysis of unit/NHS trust-level data (studies 1 and 5).

Setting

Obstetric units (OUs), alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and planned home births in England.

Participants

Studies 1–4 focused on ‘low risk’ women with ‘term’ pregnancies planning vaginal birth in 43 AMUs (n = 16,573), in 53 FMUs (n = 11,210), at home in 147 NHS trusts (n = 16,632) and in a stratified, random sample of 36 OUs (n = 19,379) in 2008–10. Study 5 focused on women with pre-existing medical and obstetric risk factors (‘higher risk’ women).

Main outcome measures

Interventions (instrumental delivery, intrapartum caesarean section), a measure of low intervention (‘normal birth’), a measure of spontaneous vaginal birth without complications (‘straightforward birth’), transfer during labour and a composite measure of adverse perinatal outcome (‘intrapartum-related mortality and morbidity’ or neonatal admission within 48 hours for > 48 hours). In studies 1 and 3, rates of intervention/maternal outcome and transfer were adjusted for maternal characteristics.

Analysis

We used (a) funnel plots to explore variation in rates of intervention/maternal outcome and transfer between units/trusts, (b) simple, weighted linear regression to evaluate associations between unit/trust characteristics and rates of intervention/maternal outcome and transfer, (c) multivariable Poisson regression to evaluate associations between planned place of birth, maternal characteristics and study outcomes, and (d) logistic regression to investigate associations between time of day/day of the week and study outcomes.

Results

Study 1 – unit-/trust-level variations in rates of interventions, transfer and maternal outcomes were not explained by differences in maternal characteristics. The magnitude of identified associations between unit/trust characteristics and intervention, transfer and outcome rates was generally small, but some aspects of configuration were associated with rates of transfer and intervention. Study 2 – ‘low risk’ women planning non-OU birth had a reduced risk of intervention irrespective of ethnicity or area deprivation score. In nulliparous women planning non-OU birth the risk of intervention increased with increasing age, but women of all ages planning non-OU birth experienced a reduced risk of intervention. Study 3 – parity, maternal age, gestational age and ‘complicating conditions’ identified at the start of care in labour were independently associated with variation in the risk of transfer in ‘low risk’ women planning non-OU birth. Transfers did not vary by time of day/day of the week in any meaningful way. The duration of transfer from planned FMU and home births was around 50–60 minutes; transfers for ‘potentially urgent’ reasons were quicker than transfers for ‘non-urgent’ reasons. Study 4 – the occurrence of some interventions varied by time of the day/day of the week in ‘low risk’ women planning OU birth. Study 5 – ‘higher risk’ women planning birth in a non-OU setting had fewer risk factors than ‘higher risk’ women planning OU birth and these risk factors were different. Compared with ‘low risk’ women planning home birth, ‘higher risk’ women planning home birth had a significantly increased risk of our composite adverse perinatal outcome measure. However, in ‘higher risk’ women, the risk of this outcome was lower in planned home births than in planned OU births, even after adjustment for clinical risk factors.

Conclusions

Expansion in the capacity of non-OU intrapartum care could reduce intervention rates in ‘low risk’ women, and the benefits of midwifery-led intrapartum care apply to all ‘low risk’ women irrespective of age, ethnicity or area deprivation score. Intervention rates differ considerably between units, however, for reasons that are not understood. The impact of major changes in the configuration of maternity care on outcomes should be monitored and evaluated. The impact of non-clinical factors, including labour ward practices, staffing and skill mix and women’s preferences and expectations, on intervention requires further investigation. All women planning non-OU birth should be informed of their chances of transfer and, in particular, older nulliparous women and those more than 1 week past their due date should be advised of their increased chances of transfer. No change in the guidance on planning place of birth for ‘higher risk’ women is recommended, but research is required to evaluate the safety of planned AMU birth for women with selected relatively common risk factors.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study

BACKGROUND

The primary aim of this study was to describe the variation in intrapartum referral rates in midwifery practices in the Netherlands. Secondly, we wanted to explore the association between the practice referral rate and a woman's chance of an instrumental birth (caesarean section or vaginal instrumental birth).

METHODS

We performed an observational study, using the Dutch national perinatal database. Low risk births in all primary care midwifery practices over the period 2008-2010 were selected. Intrapartum referral rates were calculated. The referral rate among nulliparous women was used to divide the practices in three tertile groups. In a multilevel logistic regression analysis the association between the referral rate and the chance of an instrumental birth was examined.

RESULTS

The intrapartum referral rate varied from 9.7 to 63.7 percent (mean 37.8; SD 7.0), and for nulliparous women from 13.8 to 78.1 percent (mean 56.8; SD 8.4). The variation occurred predominantly in non-urgent referrals in the first stage of labour. In the practices in the lowest tertile group more nulliparous women had a spontaneous vaginal birth compared to the middle and highest tertile group (T1: 77.3%, T2:73.5%, T3: 72.0%). For multiparous women the spontaneous vaginal birth rate was 97%. Compared to the lowest tertile group the odds ratios for nulliparous women for an instrumental birth were 1.22 (CI 1.16-1.31) and 1.33 (CI 1.25-1.41) in the middle and high tertile groups. This association was no longer significant after controlling for obstetric interventions (pain relief or augmentation).

CONCLUSIONS

The wide variation between referral rates may not be explained by medical factors or client characteristics alone. A high intrapartum referral rate in a midwifery practice is associated with an increased chance of an instrumental birth for nulliparous women, which is mediated by the increased use of obstetric interventions. Midwives should critically evaluate their referral behaviour. A high referral rate may indicate that more interventions are applied than necessary. This may lead to a lower chance of a spontaneous vaginal birth and a higher risk on a PPH. However, a low referral rate should not be achieved at the cost of perinatal safety.

Understanding Clinicians' Use of Cues When Assessing the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric Setting

Research is sparse on how clinicians' judgement informs their violence risk assessments. Yet, determining preferences for which risk factors are used, and how they are weighted and combined, is important to understanding such assessments. This study investigated clinicians' use of static and dynamic cues when assessing risk in individual patients and for dynamic cues considered in the recent and distant past. Clinicians provided three violence risk assessments for 41 separate hypothetical cases of hospitalized patients, each defined by eight cues (e.g., psychopathy and past violence severity/frequency). A clinical judgement analysis, using regression analysis of judgements for multiple cases, created linear models reflecting the major influences on each individual clinician's judgement. Risk assessments could be successfully predicted by between one and four cues, and there was close agreement between different clinicians' models regarding which cues were relevant for a given assessment. However, which cues were used varied between assessments: history of recent violence predicted assessments of in-hospital risk, whereas violence in the distant past predicted the assessed risk in the community. Crucially, several factors included in actuarial/structured risk assessment tools had little influence on clinicians' assessments. Our findings point to the adaptivity in clinicians' violence risk assessments, with a preference for relying on information consistent with the setting for which the assessment applies. The implication is that clinicians are open to using different structured assessment tools for different kinds of risk assessment, although they may seek greater flexibility in their assessments than some structured risk assessment tools afford (e.g., discounting static risk factors).

KEY PRACTITIONER MESSAGE

Across three separate violence risk assessments, clinicians' risk assessments were more strongly influenced by dynamic cues that can vary over time (e.g., level of violence) than by static cues that are fixed for a given individual (e.g., a diagnosis of psychopathy). The variation in the factors affecting risk assessments for different settings (i.e., in hospital versus in the community) was greater than the variability between clinicians for such judgements. The findings imply a preference for risk assessment strategies that offer flexibility: either using different risk assessment tools for different purposes and settings or employing a single tool that allows for different inputs into the risk assessment depending upon the nature of the assessment. The appropriateness of these clinical intuitions about violence risk that are implied by our findings warrants further investigation.

Variation in intrapartum referral rates in primary midwifery care in the Netherlands: a discrete choice experiment

OBJECTIVE

in midwife-led care models of maternity care, midwives are responsible for intrapartum referrals to the obstetrician or obstetric unit, in order to give their clients access to secondary obstetric care. This study explores the influence of risk perception, policy on routine labour management, and other midwife related factors on intrapartum referral decisions of Dutch midwives.

DESIGN

a questionnaire was used, in which a referral decision was asked in 14 early labour scenarios (Discrete Choice Experiment or DCE). The scenarios varied in woman characteristics (BMI, gestational age, the preferred birth location, adequate support by a partner, language problems and coping) and in clinical labour characteristics (cervical dilatation, estimated head-to-cervix pressure, and descent of the head).

SETTING

primary care midwives in the Netherlands.

PARTICIPANTS

a systematic random selection of 243 practicing primary care midwives. The response rate was 48 per cent (117/243).

MEASUREMENTS

the Impact Factor of the characteristics in the DCE was calculated using a conjoint analysis. The number of intrapartum referrals to secondary obstetric care in the 14 scenarios of the DCE was calculated as the individual referral score. Risk perception was assessed by respondents׳ estimates of the probability of eight birth outcomes. The associations between midwives׳ policy on management of physiological labour, personal characteristics, workload in the practice, number of midwives in the practice, and referral score were explored.

FINDINGS

the estimated head-to-cervix pressure and descent of the head had the largest impact on referral decisions in the DCE. The median referral score was five (range 0-14). Estimates of probability on birth outcomes were predominantly overestimating actual risks. Factors significantly associated with a high referral score were: a low estimated probability of a spontaneous vaginal birth (p=0.007), adhering to the active management policy Proactive Support of Labour (PSOL) (p=0.047), and a practice situated in a rural area or small city (p=0.016).

KEY CONCLUSIONS

there is considerable variation in referral decisions among midwives that cannot be explained by woman characteristics or clinical factors in early labour. A realistic perception of the possibility of a spontaneous vaginal birth and adhering to expectant management can contribute to the prevention of unwarranted medicalisation of physiological childbirth.

IMPLICATIONS FOR PRACTICE

awareness of variation in referrals and the associated midwife-related factors can stimulate midwives to reflect on their referral behavior. To diminish unwarranted variation, high quality research on the optimal management of a physiological first stage of labour should be performed.

Identifying and enhancing risk thresholds in the detection of elder financial abuse: a signal detection analysis of professionals' decision making

BACKGROUND

Financial abuse of elders is an under acknowledged problem and professionals' judgements contribute to both the prevalence of abuse and the ability to prevent and intervene. In the absence of a definitive "gold standard" for the judgement, it is desirable to try and bring novice professionals' judgemental risk thresholds to the level of competent professionals as quickly and effectively as possible. This study aimed to test if a training intervention was able to bring novices' risk thresholds for financial abuse in line with expert opinion.

METHODS

A signal detection analysis, within a randomised controlled trial of an educational intervention, was undertaken to examine the effect on the ability of novices to efficiently detect financial abuse. Novices (n = 154) and experts (n = 33) judged "certainty of risk" across 43 scenarios; whether a scenario constituted a case of financial abuse or not was a function of expert opinion. Novices (n = 154) were randomised to receive either an on-line educational intervention to improve financial abuse detection (n = 78) or a control group (no on-line educational intervention, n = 76). Both groups examined 28 scenarios of abuse (11 "signal" scenarios of risk and 17 "noise" scenarios of no risk). After the intervention group had received the on-line training, both groups then examined 15 further scenarios (5 "signal" and 10 "noise" scenarios).

RESULTS

Experts were more certain than the novices, pre (Mean 70.61 vs. 58.04) and post intervention (Mean 70.84 vs. 63.04); and more consistent. The intervention group (mean 64.64) were more certain of abuse post-intervention than the control group (mean 61.41, p = 0.02). Signal detection analysis of sensitivity (A´) and bias (C) revealed that this was due to the intervention shifting the novices' tendency towards saying "at risk" (C post intervention -.34) and away from their pre intervention levels of bias (C-.12). Receiver operating curves revealed more efficient judgments in the intervention group.

CONCLUSION

An educational intervention can improve judgements of financial abuse amongst novice professionals.

Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study

BACKGROUND

In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration.

METHODS

This was a secondary analysis of data collected in a national prospective cohort study including 27,842 'low risk' women with singleton, term, 'booked' pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer.

RESULTS

The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8-10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers.

CONCLUSIONS

Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women.