Assessing Australian and New Zealand Prehospital Clinicians’ Training, Experience, and Confidence with Out-of-Hospital Childbirths A Mixed Methods Online Questionnaire
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Abstract
Introduction: Unplanned out-of-hospital births (OOHBs) pose significant risks, particularly in rural areas where access to maternity services and response times may be limited. Given that OOHBs are uncommon, prehospital clinicians use these specialized skills infrequently, leading to skill and knowledge decay, impacting clinician preparedness and confidence in managing these presentations. This research investigates prehospital clinicians’ perceptions of training, experience, and confidence in managing OOHBs.
Methods: Australian and New Zealand paramedics and volunteers were recruited via social media and asked to complete a cross-sectional mixed-methods questionnaire. Training and exposure were assessed via multiple-choice, matrix, or open-text responses. Confidence in recognizing and managing an OOHB situation (antenatal, second stage, third stage, and postpartum care) was assessed utilizing summed scores of Likert scale responses. Independent samples t-tests compared means between groups.
Results: In total, 222 participants were included in the study, with 147 (66%) being female. Participant ages ranged from 18–72 years old. One hundred and sixty-eight participants (76%) had exposure to laboring or birthing patients prehospitally, and 123 (55%) participants had assisted with at least one OOHB. Complications reported (n=531) included stillbirth, neonatal death, postpartum hemorrhage, and maternal death. Obstetrics refresher training was undertaken by 141 participants in the previous 12 months.
Participants who had previous experience managing an OOHB were significantly more confident recognizing and managing an OOHB compared to participants without previous management experience. Paramedics expressed more confidence recognizing and managing OOHB situations compared to volunteers. However, for participants with children, confidence was only greater for antenatal care (not second stage, third stage, and postnatal care) compared to participants without children.
Conclusion: Participants with prior real-world exposure to OOHBs indicate a greater level of confidence in recognizing and managing OOHB situations. Targeted, practical training and ongoing in-service education are recommended to build capability and improve outcomes in these high-risk, low-frequency events.
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References
Astbury, J., Ferguson, J., Silverthorne, J., Willis, S., & Schafheutle, E. (2021). High-fidelity simulation-based education in pre-registration healthcare programmes: A systematic review of reviews to inform collaborative and interprofessional best practice. Journal of Interprofessional Care, 35(4), 622–632. https://doi.org/10.1080/13561820.2020.1762551
Australasian College of Paramedicine. (n.d.). Advancing Paramedicine. Retrieved December 10, 2024, from https://paramedics.org
Australian Bureau of Statistics. (2022). Location Census. https://www.abs.gov.au/statistics/people/people-and-communities/location-census/latest-release
Australian Bureau of Statistics. (2023). Sample size calculator. https://www.abs.gov.au/websitedbs/d3310114.nsf/home/sample+size+calculator
Australian Institute of Health and Welfare. (2024). Australia’s mothers and babies: Place of birth. https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/place-of-birth
Beeram, M., Solarin, K., Young, M., & Abedin, M. (1995). Morbidity and mortality of infants born before arrival at the hospital. Clinical Pediatrics, 34(6), 313–316. https://doi.org/10.1177/000992289503400604
Berry, S. N., Marko, T., & Oneal, G. (2021). Qualitative interpretive metasynthesis of parents’ experiences of perinatal loss. Journal of Obstetric, Gynecologic & Neonatal Nursing, 50(1), 20–29. https://doi.org/10.1016/j.jogn.2020.10.004
Birtill, M., King, J., Jones, D., Thyer, L., Pap, R., & Simpson, P. (2021). The use of immersive simulation in paramedicine education: a scoping review. Interactive Learning Environments, 1–16. https://doi.org/10.1080/10494820.2021.1889607
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
Cash, R. E., Kaimal, A. J., Clapp, M. A., Samuels-Kalow, M. E., & Camargo Jr, C. A. (2022). Change in emergency medical services-attended out-of-hospital deliveries during COVID-19 in the United States. Prehospital Emergency Care, 27(3), 303–309. https://doi.org/10.1080/10903127.2022.2074179
Cohen, J. (2013). Statistical power analysis for the behavioral sciences (2nd ed.). routledge. https://doi.org/10.4324/9780203771587
Corman, M. K., Phillips, P., & McCann, L. (2025). The future of paramedic education: Problematizing the translucent curriculum in paramedicine. Paramedicine, 22(4), 205–214. https://doi.org/10.1177/27536386251338525
CQ University Australia. (2024). PMSC12003 Special populations in paramedic practice. https://handbook.cqu.edu.au/he/units/view/PMSC12003
Dietsch, E., Shackleton, P., Davies, C., Alston, M., & McLeod, M. (2010). ‘Mind you, there’s no anaesthetist on the road’: Women’s experiences of labouring en route. Rural and Remote Health, 10(2), 241–249. https://doi.org/10.22605/rrh1371
Edith Cowan University: School of Medical and Health Sciences. (2022). Bachelor of Science (Paramedical Science). https://www.ecu.edu.au/degrees/courses/bachelor-of-science-paramedical-science
Elendu, C., Amaechi, D. C., Okatta, A. U., Amaechi, E. C., Elendu, T. C., Ezeh, C. P., & Elendu, I. D. (2024). The impact of simulation-based training in medical education: A review. Medicine, 103(27), e38813. https://doi.org/10.1097/MD.0000000000038813
Engjom, Hilde M, Morken, N.-H., Høydahl, E., Norheim, O. F., & Klungsøyr, K. (2017). Increased risk of peripartum perinatal mortality in unplanned births outside an institution: a retrospective population-based study. American Journal of Obstetrics and Gynecology, 217(2), 210-e1. https://doi.org/10.1016/j.ajog.2017.03.033
Engjom, Hilde Marie, Morken, N., Norheim, O. F., & Klungsøyr, K. (2014). Availability and access in modern obstetric care: a retrospective population-based study. BJOG: An International Journal of Obstetrics & Gynaecology, 121(3), 290–299. https://doi.org/10.1111/1471-0528.12510
Flanagan, B., Fitzpatrick, D., Andreis, F., & Jackson, R. (2024). A cross-sectional study of paramedic management of out-of-hospital obstetric emergencies. British Journal of Midwifery, 32(12), 644–653. https://doi.org/10.12968/bjom.2024.0061
Flanagan, B., Lord, B., & Barnes, M. (2017). Is unplanned out-of-hospital birth managed by paramedics ‘infrequent’,‘normal’and ‘uncomplicated’? BMC Pregnancy and Childbirth, 17(1), 436. https://doi.org/10.1186/s12884-017-1617-9
Flanagan, B., Lord, B., Reed, R., & Crimmins, G. (2019). Listening to women’s voices: The experience of giving birth with paramedic care in Queensland, Australia. BMC Pregnancy and Childbirth, 19(1), 1–9. https://doi.org/10.1186/s12884-019-2613-z
Garcia-Catena, C., Ruiz-Palomino, P., Saavedra, S., & Gonzalez-Sanz, J. D. (2023). Nurses’ and midwives’ perceptions and strategies to cope with perinatal death situations: A systematic literature review. Journal of Advanced Nursing, 79(3), 910–921. https://doi.org/10.1111/jan.15572
Gardiner, M. (2024). STORC-delivering midwifery-led care for WA women with St John Ambulance. Women and Birth, 37. https://doi.org/10.1016/j.wombi.2024.101719
Georgieva-Tsaneva, G., Serbezova, I., & Beloeva, S. (2024). Application of virtual reality, artificial intelligence, and other innovative technologies in healthcare education (nursing and midwifery specialties): Challenges and strategies. Education Sciences, 15(1), 11. https://doi.org/10.3390/educsci15010011
Hänninen, J., Pylväs, L., Wallin, A., & Eskola, J. (2023). Unplanned out-of-hospital births: Stories about the competence of paramedics and midwives. European Journal of Midwifery, 7(Supplement 1). https://doi.org/10.18332/ejm/171935
Helen Haines MP. (2024). Maternity care in the regions is vital. https://www.helenhaines.org/media/maternity-care-in-the-regions-is-vital
Hill, M., Flanagan, B., Hansen, S., Hopper, L., & Mills, B. (2024). Out-of-hospital birth training, experience and confidence of Australian rural volunteer ambulance officers. Rural and Remote Health, 24(4). https://doi.org/10.22605/RRH8788
Hill, M., Flanagan, B., Mills, B., Hansen, S., & Hopper, L. (2023). Paramedic training, experience, and confidence with out-of-hospital childbirth (OOHB) in Australia. Australasian Emergency Care, 26(2), 119–125. https://doi.org/10.1016/j.auec.2022.08.008
Huang, J., Tang, Y., Tang, J., Shi, J., Wang, H., Xiong, T., Xia, B., Zhang, L., Qu, Y., & Mu, D. (2019). Educational efficacy of high-fidelity simulation in neonatal resuscitation training: A systematic review and meta-analysis. BMC Medical Education, 19(1), 1–10. https://doi.org/10.1186/s12909-019-1763-z
Javaudin, F., Hamel, V., Legrand, A., Goddet, S., Templier, F., Potiron, C., Pes, P., Bagou, G., & Montassier, E. (2019). Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: Findings from a prospective cohort. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 27(1), 26. https://doi.org/10.1186/s13049-019-0600-z
Kılıç, S. (2016). Cronbach’s alpha reliability coefficient. Journal of Mood Disorders, 6(1), 47–48. https://doi.org/10.5455/jmood.20160307122823
Lazić, Z., & Takač, I. (2011). Outcomes and risk factors for unplanned delivery at home and before arrival to the hospital. Wiener Klinische Wochenschrift, 123. https://doi.org/10.1007/s00508-010-1505-z
MacDorman, M. F., & Declercq, E. (2019). Trends and state variations in out-of-hospital births in the United States, 2004-2017. Birth, 46(2), 279–288. https://doi.org/10.1111/birt.12411
McLelland, G., McKenna, L., Morgans, A., & Smith, K. (2018). Epidemiology of unplanned out-of-hospital births attended by paramedics. BMC Pregnancy and Childbirth, 18(1), 1–9. https://doi.org/10.1186/s12884-017-1638-4
National Rural Health Alliance. (2025). Rural Health in Australia Snapshot 2025. https://www.ruralhealth.org.au/wp-content/uploads/2025/02/NRHA-Rural-Health-in-Australia-Snapshot-2025.pdf
National University. (2024). Statistics Resources. Academic Success Centre. https://resources.nu.edu/statsresources/cohensd
Newman, M. (2022). Research protocol for delivering on the front line: A qualitative exploration of paramedics’ experiences of providing pre-hospital maternity care in the United Kingdom. British Paramedic Journal, 7(3), 44–50. https://doi.org/10.29045/14784726.2022.12.7.3.44
Örtqvist, A. K., Haas, J., Ahlberg, M., Norman, M., & Stephansson, O. (2021). Association between travel time to delivery unit and unplanned out-of-hospital birth, infant morbidity and mortality: A population-based cohort study. Acta Obstetricia et Gynecologica Scandinavica, 100(8), 1478–1489. https://doi.org/10.1111/aogs.14156
Ovaskainen, K., Ojala, R., Gissler, M., Luukkaala, T., & Tammela, O. (2015). Out-of-hospital deliveries have risen involving greater neonatal morbidity: Risk factors in out-of-hospital deliveries in one University Hospital region in Finland. Acta Paediatrica, 104(12), 1248–1252. https://doi.org/10.1111/apa.13117
Paramedicine Board Ahpra. (2021). 2020/21 Annual Summary. Annual Report. https://www.paramedicineboard.gov.au/News/Annual-report.aspx
Persson, A.-C., Engström, Å., Burström, O., & Juuso., P. (2019). Specialist ambulance nurses’ experiences of births before arrival. International Emergency Nursing, 43, 45–49. https://doi.org/10.1016/j.ienj.2018.08.002
Petrie, A., & Sabin, C. (2019). Medical statistics at a glance (Third). John Wiley & Sons.
Rouder, J., Saucier, O., Kinder, R., & Jans, M. (2021). What to do with all those open-ended responses? Data visualization techniques for survey researchers. Survey Practice, August. https://doi.org/10.29115/SP-2021-0008
Sabourin, J. N., Van Thournout, R., Jain, V., Demianczuk, N., & Flood, C. (2014). Confidence in performing normal vaginal delivery in the obstetrics clerkship: A randomized trial of two simulators. Journal of Obstetrics and Gynaecology Canada, 36(7), 620–627. https://doi.org/10.1016/S1701-2163(15)30542-9
Sheikhi, R. A., & Heidari, M. (2024). The challenges of delivery in pre-hospital emergency medical services ambulances in Iran: A qualitative study. BMC Emergency Medicine, 24(1), 156. https://doi.org/10.1186/s12873-024-01073-z
Siman-Tov, M., Strugo, R., Podolsky, T., & Blushtein, O. (2021). An assessment of treatment, transport, and refusal incidence in a National EMS’s routine work during COVID-19. American Journal of Emergency Medicine, 44, 45–49. https://doi.org/10.1016/j.ajem.2021.01.051
South Australia Ambulance Service. (2025a). Opportunities within SAAS. https://saambulance.sa.gov.au/work-with-us/who-we-employ
South Australia Ambulance Service. (2025b). SAAS Volunteer. https://saambulance.sa.gov.au/volunteer-with-us
St John Ambulance WA. (2022). Clinical Resources. Skills Matrix. https://clinical.stjohnwa.com.au/general/skills-matrix
Svedberg, E., Strömbäck, U., & Engström, Å. (2020). Women’s experiences of unplanned pre-hospital births: A pilot study. International Emergency Nursing, 51, 100868. https://doi.org/10.1016/j.ienj.2020.100868
Tackett, S., Steinert, Y., Whitehead, C. R., Reed, D. A., & Wright, S. M. (2022). Blind spots in medical education: How can we envision new possibilities? Perspectives on Medical Education, 11(6), 365–370. https://doi.org/10.1007/s40037-022-00730-y
The Council of Ambulance Authorities. (2011). The factors affecting the supply of health services and medical professionals in rural areas. https://www.aph.gov.au/DocumentStore.ashx?id=bdccdbb5-bfcd-4440-ac8a-ee4f8ae8c157
The Royal Children’s Hospital Melbourne. (n.d.). PIPER - Paediatric Infant Perinatal Emergency Retrieval. Retrieved August 22, 2023, from https://www.rch.org.au/piper
Thornton, C. E., & Dahlen, H. G. (2018). Born before arrival in NSW, Australia (2000–2011): A linked population data study of incidence, location, associated factors and maternal and neonatal outcomes. BMJ Open, 8(3), e019328. https://doi.org/10.1136/bmjopen-2017- 019328
Townsend, R., Chmielewska, B., Barratt, I., Kalafat, E., van der Meulen, J., Gurol-Urganci, I., O’Brien, P., Morris, E., Draycott, T., Thangaratinam, S., Doare, K. L., Ladhani, S., von Dadelszen, P., Magee, L. A., & Khalil, A. (2021). Global changes in maternity care provision during the COVID-19 pandemic: A systematic review and meta-analysis. EClinicalMedicine, 37, 100947. https://doi.org/10.1016/j.eclinm.2021.100947
University of the Sunshine Coast. (n.d.). Bachelor of Paramedicine. Retrieved December 18, 2024, from https://www.usc.edu.au/study/courses-and-programs/bachelor-degrees-undergraduate-programs/bachelor-of-paramedicine#program-detail
Unterscheider, J., Ma’Ayeh, M., & Geary, M. P. (2011). Born before arrival births: Impact of a changing obstetric population. Journal of Obstetrics and Gynaecology, 31(8), 721–723. https://doi.org/10.3109/01443615.2011.605484
Vagle, H., Haukeland, G. T., Dahl, B., Aasheim, V., & Vik., E. S. (2019). Emergency medical technicians’ experiences with unplanned births outside institutions: A qualitative interview study. Nursing Open, 6(4), 1542–1550. https://doi.org/10.1002/nop2.354
Vik, E. S., Haukeland, G. T., & Dahl, B. (2016). Women’s experiences with giving birth before arrival. Midwifery, 42, 10–15. https://doi.org/10.1016/j.midw.2016.09.012
Woodman, S., Bearman, C., & Hayes, P. (2021). Understanding skill decay and skill maintenance in first responders. Australian Journal of Emergency Management, 36(4), 44–49. https://doi.org/www.doi.org/10.47389/36.4.44