Helen Bryers

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 Pickstones 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.

Models of intrapartum care and women’s trade‐offs in remote and rural Scotland: a mixed‐methods study

Objective  To explore women’s preferences for, and trade‐offs between, key attributes of intrapartum care models.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training

Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. Design: Interview and postal survey. Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). Participants: Staff proportionally representative of professional groups involved in maternity care. Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for “generalists” in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

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 onsite specialist support. This has implications for the skills and competencies that are needed to practice midwifery in remote and rural settings. Whereas 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.