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

Background: The 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. Methods: The 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. Results: When 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. Conclusions: Currently 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

The influence of both individual and area based socioeconomic status on temporal trends in Caesarean sections in Scotland 1980-2000

Background: Caesarean section rates have risen over the last 20 years. Elective Caesarean section rates have been shown to be linked to area deprivation in England, women in the most deprived areas were less likely to have an elective section than those in the most affluent areas. We examine whether individual social class, area deprivation or both are related to Caesarean sections in Scotland and investigate changes over time. Methods: Routine maternity discharge data from live singleton births in Scottish hospitals from three time periods were used; 1980-81 (n = 133,555), 1990-91 (n = 128,933) and 1999-2000 (n = 102,285). Multilevel logistic regression, with 3 levels (births, postcode sector and Health Board) was used to analyse emergency and elective Caesareans separately; analysis was further stratified by previous Caesarean section. The relative index of inequality (RII) was used to assess socioeconomic inequalities. Results: Between 1980-81 and 1999-2000 the emergency section rate increased from 6.3% to 11.9% and the elective rate from 3.6% to 5.5%. In 1980-81 and 1990-91 emergency Caesareans were more likely among women at the bottom of the social class hierarchy compared to those at the top (RII = 1.14, 95%CI 1.00-1.25 and RII = 1.13, 1.03-1.23 respectively) and also among women in the most deprived areas compared to those in the most affluent (RII = 1.18, 1.05-1.32 and RII = 1.13, 1.02-1.26 respectively). In 1999-2000 the odds of an elective section were lower for women at the bottom of the social class hierarchy than those at the top (RII = 0.87, 0.76-1.00) and also lower in women in the most deprived areas compared to those in the most affluent (RII = 0.85, 0.73-0.99). Conclusions: Both individual social class and area deprivation are independently associated with Caesarean sections in Scotland. The tendency for disadvantaged women to be more likely to receive emergency sections disappeared at the same time as the likelihood of advantaged groups receiving elective sections increased

Scottish stillbirth and infant death report 1996

SIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(3) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

The management of postpartum haemorrhage A clinical practice guideline for professionals involved in maternity care

Pilot edition; Scottish Obstetric Guidelines and Audit ProjectSIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(6) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

The management of mild, non-proteinuric hypertension in pregnancy A clinical practice guideline for professionals involved in maternity care

Produced by the Scottish Obstetric Guidelines and Audit ProjectSIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(2) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Scottish stillbirth and infant death report 1998

SIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(10) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Scottish audit of the prevention of medical emergencies in labour An audit of progress towards safer childbirth

SIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(no 13) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

The preparation of the fetus for preterm delivery A clinical practice guideline for professionals involved in maternity care in Scotland

Guideline produced Jun 1997 valid until Jun 1999SIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(1) / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Operative vaginal delivery in Scotland A 20 year overview : with a chapter on multiple pregnancy in Scotland

Includes bibliographical references. Births in Scotland publication seriesAvailable from British Library Document Supply Centre- DSC:8361. 8173(no 18) / BLDSC - British Library Document Supply CentreSIGLEGBUnited Kingdo

Caesarean section in Scotland 1994/5 A national audit

SIGLEAvailable from British Library Document Supply Centre-DSC:8361.8173(4) / BLDSC - British Library Document Supply CentreGBUnited Kingdo