The Scottish Trial of Refer or Keep (the STORK study): midwives' intrapartum decision making

Objectives: To explore midwives’ intrapartum referral decisions in relation to their dispositional attitude towards risk. Design: A web-based correlation study examined the association between midwives personality (personal risk tendency); place of work (location); years experience and the timing of their decisions to make referrals (referral score) in a series of fictitious case scenarios (vignettes). Participants: Sample - 102 midwives providing labour care in both Consultant Led Units (CLU) and Community Maternity Units (CMU) from four Scottish Health Board areas. Analysis: A correlational analysis was carried out to test the association between total risk scores and midwives’ referral scores. Between-group comparisons were also conducted for experienced versus inexperienced midwives, midwives practising in consultant versus CMU settings and between the four Health Board Areas. Findings: Despite being presented with identical information in the vignettes, midwives made a wide range of referral decisions. There was no association between referral scores and measures of risk, personality or years of experience. No statistically significant difference between the referral scores of midwives working in CLUs or CMUs was observed. However, a statistically significant difference did emerge between the four Health Board areas, with midwives from one area making referrals at a significantly earlier stage. The maternity services in this area had experienced several high profile adverse events prior to this study; which may have influenced their referral behaviour (the availability heuristic), so as to make more cautious decisions. Key conclusions: There was no evidence that variability in the range of referral decisions was due to personality factors, risk propensity, experience or whether the midwife worked in a CLU or CMU. Local factors such as recent adverse events may significantly influence subsequent referral behaviour. Further research is required to identify why the midwives showed so much unexplained variability in their responses to the vignettes