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

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.

An Integrative Literature Review of the Factors That Contribute to Professional Nurses and Midwives Making Sound Clinical Decisions

“…Organizational issues that were found to affect professional nurses’ and midwives’ clinical decision making were the interprofessional dynamics arising from other healthcare professionals’ opinions in the multidisciplinary team ( n = 14) and the availability of institutional resources and support for nursing and midwifery staff ( n = 11), in particular decision‐making tools ( n = 12). Decision‐making tools could be guidelines (Cheyne et al., ; Gerdtz & Bucknall, ; Oduro‐Mensah et al., ), policies (Hirsh, Jensen, & Robinson, ; Ludwick, Meehan, Zeller, & O'Toole, ; Tai, ), protocols (Gerdtz & Bucknall, ; Lavellea & Dowling, ; Oduro‐Mensah et al., ), or standardized care, such as glucose tolerance (Rycroft‐Malone, ) or problem etiology symptoms (PES)‐format (Paans et al., ). Ethics, determined by the hospital's mission and vision, was mentioned least ( n = 1).…”

“…A variety of factors were identified that influence professional nurses’ and midwives’ clinical decision making. Only 3 of 38 studies included clinical decision making in the midwifery context (Cheyne et al., ; Oduro‐Mensah et al., ; Wu et al., ). However, the findings of this study can be used by both nurses and midwives, as in some countries, including South Africa, midwifery is part of the Bachelor in Nursing Science degree.…”

“…The factors that were most strongly influential were the physical and clinical status of the patient and the experience of the nurse or midwife. Factors were identified in a variety of settings, including obstetric units (Cheyne et al., ; Oduro‐Mensah et al., ; Wu et al., ), intensive care units (Aitken, Marshall, Elliott, & McKinley, ; Marshall et al., ; Tai, ), acute or critical care units (Bucknall, ; Cioffi, Conwyt, Everist, Scott, & Senior, ; Currey & Worrall‐Carter, ; Currey, Browne, & Botti, ; Hancock & Easen, ; Hirsh et al., ; Hoffman, Donoghue, & Duffield, ; Lavellea & Dowling, ; McNett, Doheny, Sedlak, & Ludwick, ; Rattray et al., ; Thompson et al., ), coronary care units (Bakalisa et al., ; Currey & Botti, ), emergency departments (Chung, ; Garbez, Carrieri‐Kohlman, Stotts, Chan, & Neighbor, ; Gerdtz & Bucknall, , ), psychiatric units (Dewar, Mullett, & Langdeau, ; Lindsey, ), medical/surgical wards (Harper, Ersser, & Gobbi, ; Hasegawa, Ogasawara, & Katz, ; Helmrich et al., ; King & Macleod, ; Ludwick et al., ; Pantazopoulos et al., ), and palliative and oncology wards (Searle & McInerney, ).…”

Birthing in rural South Australia: The changing landscape over 20 years

“…Concomitant to the closure of services has been the increased medicalisation of childbirth in Australia. The medicalisation of childbirth has led to persistent concerns surrounding the safety and quality of birth in rural areas, 3 with women being increasingly convinced of the need to have their pregnancies monitored by physicians. 4 These issues were all evident in the 2009 Report on Maternity Services Review.…”

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

“…The skill set and qualities required for maternity care providers in rural areas has been shown to be similar to urban colleagues; yet significantly different. Being confident and making autonomous decisions and knowing when to call for back-up are essential [7, 19–24]. An ability to work inter-professionally and collaboratively has also been highlighted as essential in rural practice [7, 20, 22].…”