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

The Contribution of Case Mix, Skill Mix and Care Processes to the Outcomes of Community Hospitals: A Population-Based Observational Study

Introduction:

Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients’ and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care.

Methods:

We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study.

Results:

53% of the patients had a BI improvement ≥10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance.

Discussion:

Heterogeneity in case mix reflects the nature of CHs, which play context-specific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey.

Conclusions:

More research is needed to study the impact of CH skill mix and care processes on patient outcomes.

International approaches to rural generalist medicine: a scoping review

BACKGROUND

Contemporary approaches to rural generalist medicine training and models of care are developing internationally as part of an integrated response to common challenges faced by rural and remote health services and policymakers (addressing health inequities, workforce shortages, service sustainability concerns). The aim of this study was to review the literature relevant to rural generalist medicine.

METHODS

A scoping review was undertaken to answer the broad question 'What is documented on rural generalist medicine?' Literature from January 1988 to April 2017 was searched and, after final eligibility filtering (according to established inclusion and exclusion criteria), 102 articles in English language were included for final analysis.

RESULTS

Included papers were analysed and categorised by geographic region, study design and subject themes. The majority of articles (80%) came from Australia/New Zealand and North America, reflecting the relative maturity of programmes supporting rural generalist medicine in those countries. The most common publication type was descriptive opinion pieces (37%), highlighting both a need and an opportunity to undertake and publish more systematic research in this area. Important themes emerging from the review were: Definition Existing pathways and programmes Scope of practice and service models Enablers and barriers to recruitment and retention Reform recommendations There were some variations to, or criticisms of, the definition of rural generalist medicine as applied to this review, although this was only true of a small number of included articles. Across remaining themes, there were many similarities and consistent approaches to rural generalist medicine between countries, with some variations reflecting environmental context and programme maturity. This review identified recent literature from countries with emerging interest in rural generalist medicine in response to problematic rural health service delivery.

CONCLUSIONS

Supported, coordinated rural generalist medicine programmes are being established or developed in a number of countries as part of an integrated response to rural health and workforce concerns. Findings of this review highlight an opportunity to better share the development and evaluation of best practice models in rural generalist medicine.

Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study

BACKGROUND

Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear.

AIM

To study the significance of relationships in rural midwifery and provide insights to inform midwifery education.

METHODS/DESIGN

Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data.

FINDINGS

Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships.

CONCLUSIONS

To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice.

IMPLICATIONS

Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.

'Living the rural experience-preparation for practice': The future proofing of sustainable rural midwifery practice through midwifery education

Rural practice presents unique challenges and skill requirements for midwives. New Zealand and Scotland face similar challenges in sustaining a rural midwifery workforce. This paper draws from an international multi-centre study exploring rural midwifery to focus on the education needs of student midwives within pre-registration midwifery programmes in order to determine appropriate preparation for rural practice. The mixed-methods study was conducted with 222 midwives working in rural areas in New Zealand (n = 145) and Scotland (n = 77). Midwives' views were gathered through an anonymous online survey and online discussion forums. Descriptive analysis was used for quantitative data and thematic analysis was conducted with qualitative data. 'Future proofing rural midwifery practice' using education was identified as the overarching central theme in ensuring the sustainability of rural midwives, with two associated principle themes emerging (i) 'preparation for rural practice' and (ii) 'living the experience and seeing the reality'. The majority of participants agreed that pre-registration midwifery programmes should include a rural placement for students and rural-specific education with educational input from rural midwives. This study provides insight into how best to prepare midwives for rural practice within pre-registration midwifery education, in order to meet the needs of midwives and families in the rural context.

Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009

BACKGROUND

Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women.

METHODS

Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors.

RESULTS

Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies.

CONCLUSION

Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland

OBJECTIVE

the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice.

DESIGN

online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis.

SETTING AND PARTICIPANTS

222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland.

FINDINGS

underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities.

KEY CONCLUSIONS

rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth.

IMPLICATIONS FOR PRACTICE

findings will inform the preparation of midwives for rural midwifery practice.

Midwives' Professional Competencies for Preventing Maternal Mortality in Disasters: A Cross-Sectional Study in Iran

OBJECTIVE

Maternal mortality may increase after a disaster. Because midwives are at the frontline of offering reproductive health care services in disasters, they should be competent.

METHODS

This was a cross-sectional, descriptive study carried out in 2015 in Tehran. The sample consisted of 361 midwives selected by use of a cluster random sampling method. Data were collected by using a questionnaire on professional competency for preventing maternal mortality in disasters.

RESULTS

The midwives' mean professional competency score was 177.74±31, which was an average level of professional competency. The level of knowledge and skills of the midwives was reported as inadequate for most items, particularly for the items of "managing mothers affected by chronic diseases," "physical trauma," "recognizing patients who needed to be referred," and "stabilizing mothers when referring them." Statistically significant relationships were observed between the midwives' competencies and age (P=0.001), work experience (P=0.054), educational level (P= 0.043), previous experience in a disaster (P=0.014), and workplace (P=0.006). These data were drawn by using Spearman's correlation, t-test, and ANOVA, respectively.

CONCLUSIONS

Given the average scores for midwives' professional competency in disasters and the inadequacy of prior training courses, extra educational programs for midwives are recommended. (Disaster Med Public Health Preparedness. 2018; 12: 305-311).

Community hospitals and their services in the NHS: identifying transferable learning from international developments – scoping review, systematic review, country reports and case studies

Background

The notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential.

Objectives

This study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care.

Methods

A multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland.

Results

The evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented.

Limitations

The use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth.

Conclusions

At a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Basic educational needs of midwifery students for taking the role of an assistance in disaster situations: A cross-sectional study in Iran

BACKGROUND

After disasters, the disaster medical assistance team composed of skilful healthcare staff should be available at the disaster site for providing care to disaster's victims. It is believed that midwives are at the front line of the disaster management team and should be prepared for providing care to mothers and children.

OBJECTIVES

To investigate the midwifery students' basic educational needs for taking the role of an assistant in disaster situations.

DESIGN

A cross-sectional study was conducted in an urban area of Iran, in year 2015.

PARTICIPANTS

Two hundred and thirty-one final-year midwifery students with bachelor and master degrees in midwifery participated in this study.

SETTING AND SAMPLES

The samples were chosen using a census method from four nursing and midwifery schools affiliated with four medical sciences universities in Tehran, Iran.

METHODS

The informed consent form was signed by the samples before data collection. The samples were asked to fill out the researcher's made questionnaires consisting of the demographic data form and the basic educational needs for taking the role of an assistant in disaster situations. The later was consisted of two parts: 'coping with disaster situations' and 'performing the triage'. The data were analysed using descriptive and inferential statistics via the SPSS software for Windows.

RESULTS

The mean score of coping with disaster situations was 31.3±8.2 (out of 45). Also, the mean score of performing the triage was 14.6±11.8 (out of 20). It was found that 68.8 and 74% of the students in coping with disaster situations and performing the triage, respectively had high and very high educational needs. The highest educational need was reported in the areas of 'time management' and 'the use of equipment in disaster situations'. About 86.8% of the students declared that academic education did not prepared them for taking roles in disaster situations. Only 10.6% passed educational courses about disasters before and 11.5% had the work experience in disaster situations. There was a statistically significant relationship between the students' age (P=0.01), participation in educational courses (P=0.005) and the work experience in disaster situations (P=0.04) and educational needs.

CONCLUSIONS

Our findings showed that the midwifery students had high needs for education regarding disaster situations. Therefore, the incorporation of disaster management content in the midwifery degree curricula is suggested.

Community Hospitals in Selected High Income Countries: A Scoping Review of Approaches and Models

BACKGROUND

There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries.

METHODS

We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis.

RESULTS

75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists.

CONCLUSIONS

Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.

Open, trusting relationships underpin safety in rural maternity a hermeneutic phenomenology study

BACKGROUND

There are interwoven personal, professional and organisational relationships to be navigated in maternity in all regions. In rural regions relationships are integral to safe maternity care. Yet there is a paucity of research on how relationships influence safety and nurture satisfying experiences for rural maternity care providers and mothers and families in these regions. This paper draws attention to how these relationships matter.

METHODS

This research is informed by hermeneutic phenomenology drawing on Heidegger and Gadamer. Thirteen participants were recruited via purposeful sampling and asked to share their experiences of rural maternity care in recorded unstructured in-depth interviews. Participants were women and health care providers living and working in rural regions. Recordings were transcribed and data interpretively analysed until a plausible and trustworthy thematic pattern emerged.

RESULTS

Throughout the data the relational nature of rural living surfaced as an interweaving tapestry of connectivity. Relationships in rural maternity are revealed in myriad ways: for some optimal relationships, for others feeling isolated, living with discord and professional disharmony. Professional misunderstandings undermine relationships. Rural maternity can become unsustainable and unsettling when relationships break down leading to unsafeness.

CONCLUSIONS

This study reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care. Relationships are founded on mutual understanding and attuned to trust matter. These relationships are forged over time and keep childbirth safe and enable maternity care providers to work sustainably. Yet hidden unspoken pre-understandings of individuals and groups build tension in relationships leading to discord. Trust builds healthy rural communities of practice within which everyone can flourish, feel accepted, supported and safe. This is facilitated by collaborative learning activities and open respectful communication founded on what matters most (safe positive childbirth) whilst appreciating and acknowledging professional and personal differences.

Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety

BACKGROUND

The precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. There is emerging international evidence that General Practitioners with Enhanced Surgical Skills (GPESS) are a well-positioned health service solution due to their generalist nature in low-volume settings. A realist review was undertaken to evaluate international evidence on efficacious models of perinatal surgical care. This article presents findings of the safety of such practice, one discrete part of the full realist review.

METHODS

This paper was derived from a larger review, which used a realist review methodology to guide the approach, and adhered to the RAMESES quality standard for realist reviews. Seven academic databases were searched in December 2013, using year (1990) and language (English) limiters in keeping with a rapid review approach. Mining of bibliographies in addition to consultation with international experts led to further inclusion of academic and grey literature up to March 2014.

RESULTS

Two hundred fifty-four articles were originally identified; 119 articles were removed from consideration for lack of fit, resulting in the review of 191 articles from the peer reviewed and grey literature. Of these, 53 pertained to safety and are considered herein. Evidence on the safety of GPESS was consistent in the literature cited. Clinical, case study, and qualitative evidence demonstrates that perinatal surgical care is equally safe when provided by GPESS and specialist physicians.

CONCLUSION

Findings allow health planners to confidently build perinatal surgical services around the contribution of GPs with enhanced surgical skills and focus on educational, regulatory, and continuing professional development mechanisms to ensure their sustainability. Volume-to-outcomes associations are variable and inconclusive with regards to safety, suggesting the need for more evidence. These findings, and the attendant health services planning directions, are reassuring as they suggest the viability of local models of care where feasible.

Team training for safer birth

Effective and coordinated teamworking is key to achieving safe birth for mothers and babies. Confidential enquiries have repeatedly identified deficiencies in teamwork as factors contributing to poor maternal and neonatal outcomes. The ingredients of a successful multi-professional team are varied, but research has identified some fundamental teamwork behaviours, with good communication, proficient leadership and situational awareness at the heart. Simple, evidence-based methods in teamwork training can be seamlessly integrated into a core, mandatory obstetric emergency training. Training should be an enjoyable, inclusive and beneficial experience for members of staff. Training in teamwork can lead to improved clinical outcomes and better birth experience for women.

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.

Out-of-hospital births and the supply of maternity units in France

Maternity unit closures in France have increased distances that women travel to deliver in hospital. We studied how the supply of maternity units influences the rate of out-of-hospital births using birth certificate data. In 2005-6, 4.3 per 1000 births were out-of-hospital. Rates were more than double for women living 30km or more from their nearest unit and were even higher for women of high parity. These associations persisted in multilevel analyses adjusting for other maternal characteristics. Long distances to maternity units should be a concern to health planners because of the maternal and infant health risks.

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.

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.

DESIGN

Mixed-methods study using discrete choice experiments (DCEs) and focus groups.

SETTING

The North of Scotland.

POPULATION

Women from the catchment areas of eight rural maternity units in the North of Scotland.

METHODS

Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery.

MAIN OUTCOME MEASURES

Preferences for attributes of intrapartum care.

RESULTS

Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances.

CONCLUSIONS

In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.

Competencies and skills for remote and rural maternity care: a review of the literature

AIM

This paper reports a review of the literature on skills, competencies and continuing professional development necessary for sustainable remote and rural maternity care.

BACKGROUND

There is a general sense that maternity care providers in rural areas need specific skills and competencies. However, how these differ from generic skills and competencies is often unclear.

METHODS

Approaches used to access the research studies included a comprehensive search in relevant electronic databases using relevant keywords (e.g. 'remote', 'midwifery', 'obstetrics', 'nurse-midwives', education', 'hospitals', 'skills', 'competencies', etc.). Experts were approached for (un-)published literature, and books and journals known to the authors were also used. Key journals were hand searched and references were followed up. The original search was conducted in 2004 and updated in 2006.

FINDINGS

Little published literature exists on professional education, training or continuous professional development in maternity care in remote and rural settings. Although we found a large literature on competency, little was specific to competencies for rural practice or for maternity care. 'Hands-on' skills courses such as Advanced Life Support in Obstetrics and the Neonatal Resuscitation Programme increase confidence in practice, but no published evidence of effectiveness of such courses exists.

CONCLUSION

Educators need to be aware of the barriers facing rural practitioners, and there is potential for increasing distant learning facilitated by videoconferencing or Internet access. They should also consider other assessment methods than portfolios. More research is needed on the levels of skills and competencies required for maternity care professionals practising in remote and rural areas.

Effectiveness of a breastfeeding peer coaching intervention in rural Scotland

BACKGROUND

Breastfeeding initiation in Scotland in 2000 was 63 percent, compared with over 90 percent in Norway and Sweden. Although peer support is effective in improving exclusivity of breastfeeding in countries where over 80 percent of women initiate breastfeeding, the evidence for effectiveness in countries with lower initiation is uncertain. Our primary aim was to assess whether group-based and one-to-one peer breastfeeding coaching improves breastfeeding initiation and duration.

METHODS

Action research methodology was used to conduct an intervention study in 4 geographical postcode areas in rural northeast Scotland. Infant feeding outcomes at birth and hospital discharge; at 1, 2, and 6 weeks; and at 4 and 8 months were collected for 598 of 626 women with live births during a 9-month baseline period and for 557 of 592 women with live births during a 9-month intervention period. Groups met in 5 locations, with 266 groups meeting in the period when intervention women were eligible to attend. Data on place of birth and length of postnatal hospital stay were also collected. Control data from 10 other Health Board areas in Scotland were compared. An intention-to participate survey about coaching participation was completed by 206 of 345 women initiating breastfeeding. Group attendance data were collected by means of 266 group diaries.

RESULTS

There was a significant increase in any breastfeeding of 6.8 percent from 34.3 to 41.1 percent (95% CI 1.2, 12.4) in the study population at 2 weeks after birth compared with a decline in any breastfeeding in the rest of Scotland of 0.4 percent from 44 to 43.6 percent (95% CI -1.2, 0.4). Breastfeeding rates increased compared with baseline rates at all time points until 8 months. However, the effect was not uniform across the 4 postcode areas and was not related to level of deprivation. Little difference was seen in receipt of information and knowledge about the availability of coaching among areas. All breastfeeding groups were well attended, popular, and considered helpful by participants. A minority of women (n = 14/206) participated in formal one-to-one coaching. Women who received antenatal, birth, and postnatal care from community midwife-led units were more likely to be breastfeeding at 2 weeks (p = 0.007) than women who received some or all care in district maternity units.

CONCLUSIONS

Group-based and one-to-one peer coaching for pregnant women and breastfeeding mothers increased breastfeeding initiation and duration in an area with below average breastfeeding rates.