Midwives' competence : is it affected by working in a rural location?

Introduction: Rising health care costs and the need to consolidate expertise in tertiary services have led to the centralisation of services. In the UK, the result has been that many rural maternity units have become midwife-led. A key consideration is that midwives have the skills to competently and confidently provide maternity services in rural areas, which may be geographically isolated and where the midwife may only see a small number of pregnant women each year. Our objective was to compare the views of midwives in rural and urban settings, regarding their competence and confidence with respect to ‘competencies’ identified as being those which all professionals should have in order to provide effective and safe care for low-risk women. Method: This was a comparative questionnaire survey involving a stratified sample of remote and rural maternity units and an ad hoc comparison group of three urban maternity units in Scotland. Questionnaires were sent to 82 midwives working in remote and rural areas and 107 midwives working in urban hospitals with midwife-led units. Results: The response rate from midwives in rural settings was considerably higher (85%) than from midwives in the urban areas (60%). Although the proportion of midwives who reported that they were competent was broadly similar in the two groups, there were some significant differences regarding specific competencies. Midwives in the rural group were more likely to report competence for breech delivery (p = 0.001), while more urban midwives reported competence in skills such as intravenous fluid replacement (p <0.001) and initial and discharge examination of the newborn (p <0.001). Both groups reported facing barriers to continuing professional development; however, more of the rural group had attended an educational event within the last month (p <0.001). Lack of time was a greater barrier for urban midwives (p = 0.02), whereas distance to training was greater for rural midwives (p = 0.009). Lack of motivation or interest was significantly higher in urban units (p = 0.006). Conclusion: It is often assumed that midwives in rural areas where there are fewer deliveries, will be less competent and confident in their practice. Our exploratory study suggests that the issue of competence is far more complex and deserves further attention.NHS Education Scotlan

Sustainable Maternity Service Provision in Remote and Rural Areas of Scotland: The scoping of core multidisciplinary skills and exploration of best practice in the development and maintenance of skills - Executive Summary

First paragraph: Health care provision in remote and rural areas of Scotland is a current cause for concern. With respect to maternity services, there are particular issues around falling fertility rates and medical workforce capacity, accompanied by a policy climate that is encouraging further centralisation of acute services. There are important implications for the sustainability of safe, local maternity care if the reduction in geographical access to acute consultant-led obstetric and neonatal services continues

The Highland experience: immersion in water in labour

In September 1997, the most northerly labouring and birthing pool in Scotland was installed at Raigmore Maternity Unit. The decision to install the pool was made in response to local demand, and this raised a number of professional issues, the most important of which concerned the use of the pool in labour suite and the demand for water birth. An audit of the first two years of the use of the pool indicates variable use, influenced perhaps by conventional baths and obstetricians who do not support water birth. Eighty seven women used the pool in labour and two women gave birth to their babies in the pool. Of these, twenty women had their labours induced. The most common reason for women leaving the pool was to obtain further analgesia. Eighty two per cent of women and 79 per cent of midwives rated the pool very highly

Risk, theory, social and medical models: A critical analysis of the concept of risk in maternity care

Background there is an on-going debate about perceptions of risk and risk management in maternity care. Objectives to provide a critical analysis of the risk concept, its development in modern society in general and UK maternity services in particular. Through the associated theory, we explore the origins of the current preoccupation with risk Using Pickstone's historical phases of modern health care, the paper explores the way maternity services changed from a social to a medical model over the twentieth century and suggests that the risk agenda was part of this process. Key conclusions current UK maternity services policy which promotes normality contends that effective risk management screens women suitable for birth in community maternity units (CMUs) or home birth: however, although current policy advocates a return to this more social model, policy implementation is slow in practice. Implications for practice the slow implementation of current maternity policy in is linked to perceptions of risk. We content that intellectual and social capital remains within the medical model

The Perception of Women in Rural and Remote Scotland About Intrapartum Care: A Qualitative Study

Background The views of mothers are important in shaping policy and practice regarding options for intrapartum care. Mothers in rural and remote areas face unique challenges accessing services, and these need to be well understood. Therefore, our aim was to understand the compromises that women who live in remote and rural settings, more than 1 h from a maternity unit, face regarding intrapartum care. Methods Qualitative semi-structured telephone interviews (n = 14) were undertaken in rural Scotland with 13 women who had young children and one who was pregnant. Interviews were transcribed and thematically analysed by two researchers. Results Key themes identified were women’s perceptions about risk and the safety of different pathways of maternity care and birth locations; the actual and perceived distance between home and the place of birth, and the type of maternity care available at a place of birth. Mothers in rural and remote areas face particular challenges in choosing where to have their babies. In addition to clinical decisions about ‘place of birth’ agreed with healthcare professionals, they have to mentally juggle the implications of giving birth when at a distance from family support and away from familiar surroundings. It was clear that many women from rural communities have a strong sense of ‘place’ and that giving birth in a geographical location, community and culture that feels familiar is important to many of them. Conclusions Health care staff need to appreciate the impact of non-clinical factors that are important to mothers in remote and rural areas and acknowledge these, even when they cannot be accommodated. Local and national policy also needs to reflect and respond to the practical challenges faced by rurality.Output Status: Forthcoming/Available Onlin

The buck stops here: Midwives and maternity care in rural Scotland

Objective: to explore and understand what it means to provide midwifery care in remote and rural Scotland. Design: qualitative interviews with 72 staff from 10 maternity units, analysed via a case study approach. Setting: remote and rural areas of Scotland. Participants: predominantly midwives, with some additional interviews with paramedics, general surgeons, anaesthetists and GPs. Findings: remote and rural maternity care includes a range of settings and models of care. However, the impact of rural geographies on decision-making and risk assessment is common to all settings. Making decisions and dealing with the implications of these decisions is, in many cases, done without on site specialist support. This has implications for the skills and competencies that are needed to practice midwifery in remote and rural settings. Where as most rural midwives reported that their skills in risk assessment and decisions to transfer were well developed and appropriate to practising in their particular settings, they perceived these decisions to be under scrutiny by urban-based colleagues and felt the need to stress their competence in the face of what they imagined to be stereotypes of rural incompetence. Conclusions: this study shows that skills in risk assessment and decision-making are central to high quality remote and rural midwifery care. However, linked to different perspectives on care, there is a risk that these skills can be undermined by contact with colleagues in large urban units, particularly when staff do not know each other well. There is a need to develop a professional understanding between midwives in different locations. Implications for practice: it is important for the good working relationships between urban and rural maternity units that all midwives understand the importance of contextual knowledge in both decisions to transfer from rural locations and the position of midwives in receiving units. Multiprofessional CPD courses have been effective in bringing together teams around obstetric emergencies; we suggest that a similar format may be required in considering issues of transfer

General Practitioner Involvement in Remote and Rural Maternity Care: Too Big a Challenge?

BACKGROUND: In the United Kingdom, general practitioner (GP) involvement in maternity care has declined significantly over the past decade. This is particularly so in remote and rural areas where midwives have stepped up and taken over units to ensure that women in these areas continue to have a service. A recent report by the King’s Fund argues for a greater role for the GP in maternity care provision; however, this raises questions about whether GPs have the skills and training to provide such care. AIM: To explore the views of GPs on the skills and training required to deliver safe and appropriate local intrapartum services in remote and rural settings. METHODS: Mixed-method study consisting of qualitative interviews with a purposive sample of GPs in six remote and rural sites. To triangulate the interview findings and identify features that might have been missed in the interviews, a questionnaire was developed using initial key themes identified. FINDINGS: Maternity care accounted for less than 10% of most remote and rural GPs’ workload, yet interviewees reported that their role required them to be competent in a wide range of procedures. This was seen as a major barrier to recruitment and retention in rural areas. Although self-reported competence and confidence was high, several GPs felt de-skilled and felt that they were fighting a losing battle to maintain skills. GPs regarded isolation, need for comprehensive expertise, limited resources, and transportation difficulties as factors affecting the decline in their contribution to remote and rural maternity care. CONCLUSION: Although rural GPs and midwives might traditionally have been in competition, providing a woman-centered service in remote areas may be easier to achieve through collaborative working. However, if GPs are to play a greater role, then they will need to be prepared to make a strategic commitment to the maintenance of remote and rural maternity care. This will require innovative methods of training, special consideration of educational needs, and incentives for practitioners to settle in rural areas, but it may already be too late for GPs to have a substantial input into maternity care