Global maternal death rates are falling but still remain ‘unacceptably high’ (World Health Organization, 2024). In Australia, the maternal mortality rate is 5.5 per 100 000 births (Australian Institute of Health Welfare, 2023). Although these rates are comparatively low compared to other countries, official reports suggest that improvements in care could have prevented deaths in a considerable proportion of these patients (Australian Institute of Health Welfare, 2023). Complications leading to mortality are relatively consistent across these countries, with thromboembolism, hypertension, sepsis and haemorrhage cited as some of the most common causes of direct maternal death (Shakespeare and Knight, 2015; Verstraeten et al, 2015; Australian Institute of Health Welfare, 2023). Some are also reported as intrapartum complications experienced during the paramedic care of obstetric patients (Flanagan et al, 2017). Notably, across Australia and the UK, between 15% and 33% of maternal deaths occur during the prehospital or emergency department phase of care (Knight et al, 2021; Australian Institute of Health Welfare, 2023). These data demonstrate that despite careful maternity planning, serious complications can and do occur outside the planned place of birth.
Births occurring in paramedic care represent approximately 0.5% of annual ambulance caseload in Queensland (Flanagan et al, 2017). Clinical knowledge and skills, particularly those used in obstetric emergencies, should be performed in accordance with evidence‑informed best practice, to ensure that the highest quality care is provided to both the mother and newborn, irrespective of how often those skills are required. However, confidence, knowledge and competency of practical skills have the potential to atrophy when used infrequently, particularly in the absence of interventions aimed at reducing these. Such knowledge and skills atrophy have been clearly demonstrated in other low frequency conditions attended by paramedics (Su et al, 2000; Garza et al, 2005).
Current learning strategies are expected to result in knowledge retention and continuing competence; however, there is a weak body of research to support this (Zieber and Sedgewick, 2018). In Australia, ambulance services are not mandated to deliver specific clinical education to ambulance clinicians and although the regulating body, the Australian Health Practitioner Regulation Agency (2019) mandate a minimum of 30 hours of continuing professional development, topic areas are not specified.
Childbirth and pregnancy related illnesses are consistently classified in the literature as responses that are one of the most stressful for paramedics (Dawson et al, 2003; Bohström et al, 2017). This stress is reported to stem from the infrequency of such cases, a lack of control over the situation, a limited understanding of childbirth and the risk of potential complications (McLelland et al, 2014; Bohström et al, 2017). Several studies emphasise the importance of good training and preparation to deal with these challenging cases (Alexander and Klein, 2001; Regehr et al, 2002; Bohström et al, 2017). There are concerns for poor maternal and neonatal outcomes when birth occurs in paramedic care and a reported lack of confidence among paramedics in the management of pregnancy related cases (Moscovitz et al, 2000; Rodie et al, 2002). Specifically, education provided to paramedics in both undergraduate and postgraduate curricula, concerning the management of birth and potential pregnancy related complications, warrants further review (Haloob and Thein, 1992; Moscovitz et al, 2000; Rodie et al, 2002; Scott and Esen, 2005; Loughney et al, 2006; McLelland et al, 2014).
This research aimed to seek the experiences of Queensland Ambulance Service registered paramedics to facilitate a robust evaluation of paramedics’ knowledge, attitudes and practice concerning the out‑of‑hospital management of physiological birth and birth complications.
Methods
A cross‑sectional study was undertaken to explore the perceived and actual learning needs, knowledge, attitudes and practices of registered paramedics to respond to obstetric emergencies. All registered paramedics employed by the Queensland Ambulance Service were invited to be surveyed (convenience sample).
Participants had access to the service's clinical guidelines and detailed instructions for clinical procedures while undertaking the survey and had completed annual in‑service educational activities concerning obstetrics emergency management within the last 12 months; the survey was therefore well‑timed to evaluate the knowledge and future learning needs of employees who had access to and participated in routine professional development opportunities. The reporting of this study conforms to the STROBE statement (Elm et al, 2007).
Participants
The survey was aimed at registered paramedics currently employed in an operational and/or educational capacity. Participants had varied clinical levels and were from vocational and/or tertiary educational backgrounds. An advanced care paramedic is the minimum level for a qualified paramedic in Queensland who has an undergraduate bachelor's degree or equivalent and a critical care paramedic has a minimum Graduate Diploma in Intensive Care Paramedical Practice or equivalent; participants were from different geographical locations.
Data collection
There was no previously published or validated measurement tool in this area and, as such, a pragmatic approach was taken to survey development. The survey was developed by a research team comprising of a statistician and paramedic educators (n=3), including two paramedic/midwives. The premise of the survey was consistent with a knowledge, attitude and practice instrument (Gumucio et al, 2011; Wang et al, 2015). A knowledge, attitude and practice survey is intended to be representative of a target population and is used frequently in the health sciences for patients and healthcare workers. These surveys can assess health‑related beliefs and behaviours from the perspective of specific illnesses or specific treatments (Australian Bureau of Statistics, 2021). A knowledge, attitude and practice survey should ideally precede an education programme. The results inform the topics and design of an effective programme, as well as the baseline data for the future evaluation of the success of a programme (Andrade et al, 2020).
Six key domains of care were identified (informed by core teaching domains): antepartum complications, physiological birth, intrapartum complications, maternal postpartum complications, trauma in pregnancy and newborn care. Each domain included four related questions aimed at measuring the respective level of knowledge of each participant. Corresponding questions pertinent to each area of care were informed through existing literature, clinical texts, and the knowledge/experience of the investigators.
Once developed, the questions were reviewed by a stakeholder group of 6 paramedics and 4 midwives with expertise in prehospital maternal care and education. They were invited to rate the clarity, structure and format of the questions in each of the domains and had the opportunity to make further suggestions. Overall feedback was very positive, recommending only a small number of adjustments. The study was subsequently piloted by 10 experienced paramedics prior to being finalised; feedback determined questions to have high face validity for each domain.
Participants were asked to self‑rate their level of knowledge in each of the six obstetric domains. Available options were provided on a 3‑point performance scale (weak, adequate, excellent). Assessed knowledge was measured by a series of targeted questions within each domain. Overall strength of knowledge was computed based on the responses to each of the questions in that domain. A score of 50% or less was categorised as a weak level of knowledge, 75% was considered adequate, and 100% was categorised as excellent.
A questionnaire was used to examine the paramedics’ attitude toward the training received during both initial training (as a student paramedic) and in‑service education (as a registered paramedic).
An email with a link to the survey was sent by the employer, on behalf of the research team, to operational staff in January 2021. The 2000 potential participants were given 6 weeks to reply, accounting for staff leave.
Data analysis
Survey responses were analysed in R (4.2.0). Summary statistics are presented as frequency distributions, percentages, means/medians and interquartile ranges as appropriate. These analyses are intentionally descriptive only, so statistical testing is not appropriate and was not performed. Spearman's measure of correlation was used to observe linear correlations between ranks of the observations, rather than the observations themselves, because these variables are not numerical, rather ordinal. The classic Pearson's correlation index provides a measure of the strength and direction of a linear relationship between continuous variables; here, the (less restrictive) monotonic relationship was explored, because the assumption of linearity may not be reasonable with Likert scale‑valued variables. Missing information was not inputed.
Ethical considerations
Consent to participate was requested at the beginning of the survey. Ethics approval was granted by the University of the Sunshine Coast Human Research Ethics Committee (reference: A201469).
Results
A total of 264 participants completed the survey (~13.2% response rate). General demographic characteristics are summarised in Table 1. The median age of participants was 32 years (interquartile range: 22, 64). Participants’ gender identities were 56.8% female and 42.4% male; less than 1% preferred not to describe their gender identity. Professional demographics, specifically educational level, years of service and clinical grade are also presented in Table 1.
| Category | Frequency, n=264 (%) | |
|---|---|---|
| Education | Diploma | 29 (11.0) |
| Undergraduate | 183 (69.3) | |
| Postgraduate | 52 (19.7) | |
| Years of service | <5 | 71 (26.9) |
| 5–10 | 79 (29.9) | |
| 11–15 | 45 (17.0) | |
| 16–20 | 27 (10.2) | |
| >20 | 42 (15.9) | |
| Clinical grade | Advanced care paramedic | 216 (81.1) |
| Critical care paramedic | 32 (12.1) | |
| Non-operational clinician/manager | 12 (4.5) | |
| Other | 4 (1.6) |
The median number of self‑reported births attended to‑date during their career was 2.0 (range: 0–65). Figure 1 provides a visual approximation of the distribution of self‑reported exposure to births by clinical grade. Of all groups, critical care paramedics self‑reported the highest exposure to births, ranging between 0 and 30. Some outliers existed, with some participants self‑reporting around 50 births. Should assistance at a scene be required in the event of a complication, n=243 (92%) participants stated that they were able to either consult on the phone or request assistance at the scene from a doctor or midwife. However, n=8 (3.0%) reported having no ability to consult or request medical or midwifery back up because of their remote location.
Table 2 shows participants’ self‑rated knowledge in the six specific obstetric areas. The proportion of participants with correct responses to specific questions, as well as the overall strength of knowledge for each domain, are reported in Table 3.
| Topic area | Response, n=264 (%) | ||
|---|---|---|---|
| Weak | Adequate | Excellent | |
| Antepartum complications | 86 (32.6) | 171 (64.8) | 7 (2.7) |
| Physiological birth | 20 (7.6) | 200 (75.8) | 44 (16.7) |
| Intrapartum (birth) complications | 69 (26.1) | 184 (69.7) | 11 (4.2) |
| Maternal postpartum complications | 60 (22.7) | 181 (68.6) | 23 (8.7) |
| Trauma in pregnancy | 106 (40.2 | 146 (55.3) | 12 (4.5) |
| Newborn care (including resuscitation) | 39 (14.8) | 193 (73.1) | 32 (14.8) |
| Items | Correct, n=264 (%) | ||
|---|---|---|---|
| Domain 1: antepartum complications | |||
| Ectopic pregnancy | 204 (77.3) | ||
| Placenta previa | 84 (31.8) | ||
| Pre-eclampsia | 124 (84.8) | ||
| Antepartum haemorrhage | 124 (47.0) | ||
| Overall strength of knowledge in domain | Weak: 131 (49.6) | Adequate: 110 (41.7) | Excellent: 23 (8.7) |
| Domain 2: physiological birth | |||
| Optimal position for transport | 168 (63.8) | ||
| Directed pushing | 58 (22.0) | ||
| Identifying placental separation | 238 (90.5) | ||
| Breech manoeuvres | 115 (43.6) | ||
| Overall strength of knowledge in domain | Weak: 131 (65.2) | Adequate: 110 (28.8) | Excellent: 23 (6.1) |
| Domain 3: intrapartum complications | |||
| Signs of dystocia | 170 (64.4) | ||
| Cause of dystocia | 190 (72.2) | ||
| Cord prolapse | 169 (64.0) | ||
| Breech | 231 (87.5) | ||
| Overall strength of knowledge in domain | Weak: 87 (33.0) | Adequate: 102 (38.6) | Excellent: 75 (28.4) |
| Domain 4: postpartum complications | |||
| Definition of primary postpartum harmorrhage | 194 (73.5) | ||
| Assessment of 4 Ts (tone, tissue, trauma, thrombin) | 219 (83.0) | ||
| Eclampsia in postpartum period | 214 (81.4) | ||
| Secondary postpartum haemorrhage | 262 (99.5) | ||
| Overall strength of knowledge in domain | Weak: 34 (12.9) | Adequate: 90 (34.1) | Excellent: 140 (53.0) |
| Domain 5: trauma in pregnancy | |||
| Abrupto placentae | 62 (23.5) | ||
| Abrupto placentae effect on fetus | 116 (44.0) | ||
| Amniotic fluid embolism | 32 (12.1) | ||
| Resuscitation care | 240 (90.9) | ||
| Overall strength of knowledge in domain | Weak: 219 (12.9) | Adequate: 43 (34.1) | Excellent: 2 (0.8) |
| Domain 6: newborn care | |||
| Apgar score | 211 (79.9) | ||
| Respiratory distress in hypothermia | 121 (45.8) | ||
| Actions immediately after birth | 263 (99.6) | ||
| Vital signs | 182 (68.9) | ||
| Overall strength of knowledge in domain | Weak: 74 (83.0) | Adequate: 118 (16.3) | Excellent: 72 (27.3) |
Perceived vs assessed knowledge
Overall, there were weak correlations (eg less than r=0.15) between perceived and assessed knowledge in each of the domains. Visual representation of the crosstabulations are shown in Figure 2 (A–F) as heat maps on a red spectrum palette, where a lighter color corresponds to lower observed proportions, and a darker one to higher. Some discernable patterns between perceived and assessed knowledge can be identified. The plots represent each domain measured; frequency counts are included where perceived knowledge (horizontal x axis) and assessed knowledge (vertical y‑axis) cross.
Overall, very few participants reported their knowledge in any domain as being ‘excellent’ (meaning, the last column of each graph is typically lighter than the rest). The patterns demonstrated in Figure 2A and 2B (antepartum complications and physiological birth) are similar. A considerable proportion of those who self‑reported ‘adequate’ knowledge in these subject areas were categorised as having weak assessed knowledge. For antepartum complications, of participants whose perceived knowledge was adequate, 48% (n=82/171) had weak and 42% (n=71/181) had adequate assessed knowledge. For physiological birth, almost two‑thirds (n=113/180) of respondents with perceived adequate knowledge demonstrated weak assessed knowledge.
Figure 2C (intrapartum complications) and 2F (newborn care) also show similar patterns, but with a larger proportion of participants self‑reporting adequate knowledge having adequate assessed knowledge. One‑third of participants with perceived adequate knowledge on intrapartum complications also had adequate assessed knowledge (n=66/184), and 46% (n=88/193) of those with perceived adequate knowledge on newborn care were categorised as having adequate assessed knowledge. However, greater variability was observed in these domains, with comparable proportions of participants who perceived themselves to have adequate knowledge being categorised as having weak or excellent assessed knowledge (Figure 2C: weak n=64/184, excellent n=54/184; Figure 2F: weak n=56/193, excellent n=49/193). This may reflect a lack of awareness of actual knowledge or an increased or decreased level of confidence.
In Figure 2D (postpartum complications), while two‑thirds of participants self‑reported adequate knowledge, over half of these (n=101/181) demonstrated excellent assessed knowledge, and 34% (n=62/181) had adequate assessed knowledge. In Figure 2E (trauma in pregnancy), despite 46% of the sample reporting adequate knowledge in this area, most of these (n=123/146; 84%) were assessed as having weak knowledge. This domain also saw the fewest participants perceiving excellent knowledge, which may indicate the participants have an awareness of a knowledge gap. Of all domains measured, assessed knowledge was weakest in domains 2 (physiological birth) and 5 (trauma in pregnancy), and highest in domain 4 (postpartum complications).
Attitude to education on obstetric emergencies
Figure 3 outlines participants’ responses to the questionnaire on their attitude to the education they received for obstetric emergencies. Overall, between 43% and 49% of participants agreed that training had been adequate, whether as a student or qualified paramedic. The majority (70%) strongly disagreed with the statement on having the opportunity to undertake clinical placement in a maternity unit, and 60% strongly agreed that they were keen to receive regular in‑service education (at least annually) in both obstetric emergencies and neonatal resuscitation.
Confidence in responding to obstetric emergencies
Participants generally strongly agreed (74%) that having a comprehensive understanding of the management of obstetric emergencies and providing optimal neonatal care was important. As shown in Figure 4, participants reported to be reasonably skilled in recognising and managing complications, but were neutral to feeling confident in doing so (24% somewhat disagreed, 24% were neutral and 40% somewhat agreed).
Discussion
This is one of the first studies to investigate obstetric knowledge in an Australian ambulance service. Its descriptive nature afforded a ‘temperature check’ of the current knowledge status of the participating ambulance clinicians. Although few studies have been published in this area, other national and international studies report similar low exposure (McLelland et al, 2016; Cash et al, 2021; Heys et al, 2022) and low confidence (Heys et al, 2022; Hill et al, 2023), and that up to one‑third of obstetric related calls were of high clinical acuity (Hill et al, 2023). As a low frequency, potentially high acuity condition, education on obstetric and neonatal care deserves attention.
Participants reported that the lack of exposure to obstetric emergencies impacted their confidence, and less than half felt confident in managing an obstetric or neonatal emergency in the community. A lack of exposure in similar low frequency, high acuity prehospital populations has been associated with lower confidence and, along with lack of training, linked to significant adverse events (Duby et al, 2018; Meckler et al, 2018) and the potential for poorer outcomes (Dyson et al, 2016). Studies have also reported obstetric adverse incidents to be costly, not only in terms of outcome but also litigation (Dobbie and Cooke, 2008).
Several studies have demonstrated significant variability in ambulance clinicians’ confidence, knowledge and skills in obstetric and neonatal care (Madar et al, 2017; Mileder et al, 2019; Huynh et al, 2021). In the present study, despite almost all participants reporting receiving regular training to be important, significantly fewer reported regularly taking part in either obstetric or neonatal practice. It is likely that a lack of exposure and infrequent practice opportunities result in rapid fade of associated clinical skills (Hamilton, 2005). Fortunately, there is evidence to suggest that frequent exposure to resuscitation simulation training can produce demonstrable improvement in skills and knowledge in a simulated setting (Mileder et al, 2019) and some studies on neonatal populations have demonstrated mortality reductions of up to 30% (Lee et al, 2012; Dempsey et al, 2015; Mduma et al, 2015).
An opportunity exists for increasing the frequency of obstetric training. There are good theoretical and scientific rationales to recommend education and simulation to ensure optimum outcomes for maternal and newborn patients. Evidence from the present study, and others (Cash et al, 2021; Hill et al, 2023), suggests that existing education strategies may benefit from enhancement to improve knowledge, confidence and outcomes. Multidisciplinary educational approaches have also proven to be successful in some countries. For example, the Pre‑Hospital Practical Obstetric Multi‑Professional Training (Abdelrahman and Murnaghan, 2013) and Scottish Core Obstetric Teaching and Training in Emergencies Course (Howie et al, 2011) are two UK‑based courses delivering bespoke prehospital maternal and newborn care education to prehospital clinicians.
Although it is straightforward to suggest an educational update every 6–12 months, as this is where knowledge and skills are reported to fade, a recent review has determined there is great variability in the pace of fade and can be individualised (Duby et al, 2018). Acknowledging individual variation in clinicians is important, particularly where there is discord between their personal perceptions and assessed strength of knowledge. The results of the present study indicate a very weak association (sometimes even marginally inverse) between perceived and assessed strength of knowledge for some domains. Despite many participants perceiving their knowledge as adequate, their assessed knowledge in several domains was weak. In psychology, the Dunning‑Kruger Effect compares subjective and objective self‑assessment, presenting as overestimation of skill or competency by low performers and underestimation by high performers (Kruger and Dunning, 1999). This has been demonstrated to negatively impact patient care in other paramedic/emergency medical technician focused studies (Cushman et al, 2010; Saposnik et al, 2016;Yang et al, 2022).
Infrequent exposure to obstetric and neonatal emergencies implies that many paramedics are relative novices and therefore the ‘post‑hoc’ application of this psychological theory may suggest an overestimation of participants’ knowledge or skills in these areas. This indication of discord represents a critical finding in this study. Furthermore, there is a significant body of literature on medical error related to overconfidence, and some evidence suggests that it can be associated with both positive and negative learning experiences (Dunlosky et al, 2013; Trifunovic–Koenig et al, 2022).
Implications for practice
While this study was not designed to be generalisable, it highlights an important aspect of education planning, where traditionally clinicians’ self‑reported needs for education have been accepted at face value. With a slight adaptation of traditional engagement processes and more innovative approaches, using methods such as that of this study, knowledge gaps may be more objectively assessed. This has the potential to mitigate associated risks through identification of knowledge and skills ‘blind spots’ (both perceived and actual). Once cognitive biases, such as overconfidence, are identified, the unknowns become known and strategies to mitigate these contributing factors can be developed, tested and introduced; thus, education input becomes more focused and meaningful.
Limitations
This study was not designed to be generalisable nor was it a fully validated tool. It forms an exploratory pilot on ambulance clinicians’ knowledge and skill around obstetric and newborn care. There are several limitations. First, participants had the ability to compare answers with colleagues if completing the survey at the same time and with the added availability of comprehensive clinical guidelines as a reference point. However, to mitigate the latter, questions were developed from the perspective of requiring a deeper understanding and clinical reasoning, not rote learning of guideline details. Second, the non‑probabilistic nature of the survey design (convenience sampling), as well as possible selection bias (for example, participants more likely to take an active part in maintaining their obstetric knowledge or have particular experiences that that motivated them to participate), missing data (mainly as a result of non‑response and attrition) and the low response rate preclude generalisability of the results. Finally, measurement bias was possible. The survey instrument was designed for this study and has not yet been fully validated. Findings regarding assessed knowledge may reflect the measurement of knowledge, rather than actual knowledge of participants on this topic. Further, it is possible that the measurement of knowledge in this survey does not relate to practice. For these reasons, the results should be interpreted with caution.
Conclusions
This study measured and compared paramedics’ perceived and assessed levels of obstetric knowledge, and opportunities for obstetric and neonatal education. It provides an important preliminary insight into the variability of perceived and assessed knowledge in a paramedic population and their perceptions of obstetric emergencies. More research is required to confirm the conclusions, with more participants, and using more rigorously validated measures of assessed knowledge that robustly reflect actual knowledge and practice. The moderate levels of confidence in managing obstetric emergencies reported by the study participants suggest a further need for education in this area. The frequency and type of education provided would benefit from further investigation.