Risk assessment and decision making about in-labour transfer from rural maternity care:

a social judgement and signal detection analysis

Helen Cheyne, H, Len Dalgleish, Janet Tucker, Fiona Kane, Ashalatha Shetty, Sarah McLeod, Catherine Niven

Research output: Contribution to journalArticle

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Abstract

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.
Original languageEnglish
Article number122
Number of pages13
JournalBMC Medical Informatics and Decision Making
Early online date31 Oct 2012
DOIs
Publication statusPublished - 31 Oct 2012

Fingerprint

Decision Making
Midwifery
Rural Population
Obstetric Labor
Parturition
Transfer Factor
Aptitude
Clinical Competence
Psychological Signal Detection
Developed Countries
Emotions
Guidelines
Delivery of Health Care
Safety
Weights and Measures

Keywords

  • Decision making
  • Risk Assessment
  • Rural
  • Labor
  • Maternity care
  • Social judgement theory
  • signal detection theory (SDT)

Cite this

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgement and signal detection analysis. / Cheyne, H, Helen; Dalgleish, Len; Tucker, Janet ; Kane, Fiona; Shetty, Ashalatha; McLeod, Sarah; Niven, Catherine.

In: BMC Medical Informatics and Decision Making, 31.10.2012.

Research output: Contribution to journalArticle

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abstract = "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.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.",
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note = "PMCID: PMC3536665 Thanks are due to the midwives and obstetricians who participated in this study. The study was funded by a research grant from the Scottish Government Chief Scientist’s Office ref CZH/4/417. Thanks also to Prof Brian Williams for his very helpful comments on the paper. Authors’ contributions HC conceived of the study, participated in its design, coordinated the study and wrote the manuscript. LD developed the study method, participated in the design of the study, performed the statistical analysis and wrote the study final report with HC. JT participated in the design of the study, analysis of data and helped to draft and revise the manuscript. FK organised the study, collected the data, contributed to the analysis and the drafting of the manuscript. AS contributed to the study design and the drafting of the manuscript, SMcL contributed to the study design and the drafting of the manuscript, CN contributed to the study design and the drafting of the manuscript. Where possible all authors read and approved the final manuscript.",
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AB - 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.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.

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