BMC Med Inform Decis Mak - Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis.

Tópicos

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Resumo

CKGROUND: 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.

Resumo Limpo

ckground import respect women wish give birth close local communiti support polici mani develop countri howev persist concern qualiti safeti matern care rural communiti express safe childbirth rural communiti depend good risk assess decis make whether transfer woman labour obstetr led unit requir difficult decis wide variat transfer rate rural matern unit report suggest differ decis make criteria may involv furthermor rural midwiv famili doctor report feel isol make decis staff urban centr understand difficulti face order develop evid base decis make strategi greater understand way matern care provid current make decis requir studi aim examin midwiv work urban rural set obstetrician make intrapartum transfer decis describ sourc variat decis makingmethod studi conduct three stage midwiv four obstetrician describ factor influenc transfer decis vignett depict intrapartum scenario develop base stage one data vignett present midwiv obstetrician ask assess level risk case decid whether transfer social judgment analysi use identifi factor factor weight use assess signal detect analysi use identifi particip abil distinguish high low risk case person decis thresholdsresult review case inform vignett midwiv differ set obstetrician made similar risk assess despit wide rang transfer decis still made suggest main sourc variat decis make transfer rate assess person decis threshold cliniciansconclus current health care practic focus support improv decis make skill train clinic guidelin howev method alon unlik effect improv consist decis make

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