Unveiling paramedic confidence: exploring paramedics' perceived confidence in out-of-hospital births and obstetric emergencies – a scoping review

Introduction

Over the past 20 years, nearly half of Australia’s birthing centres, predominantly in rural areas, have closed, resulting in the centralisation of birthing care^1,2. The Rural Doctors Association reported that, between 1992 and 2011, over 225 rural birthing centres were closed, representing more than a 40% reduction in Australia’s rural birthing facilities². This substantial reduction in rural birthing centres has correlated with a 47% increase in births occurring before reaching hospitals². Consequently, this trend positions paramedics as essential primary healthcare providers, responsible for managing out-of-hospital births and assisting women who give birth en route to medical facilities or opt for home births. Although high-risk pregnancies identified in the early stages are typically referred to regional or metropolitan birthing centres with greater capacity to manage the anticipated level of risk, ultimately not all births occur at these specialised facilities². While obstetric emergencies remain relatively rare occurrences for paramedics, they signify instances of elevated acuity and risk, necessitating a strong sense of clinical confidence in their management due to their association with substantially heightened rates of complications^3-8, as evidenced by a reported perinatal mortality rate of 15 per 1000 for out-of-hospital births compared to 5 per 1000 for in-hospital births^4-9. Evidence highlights the comparably poorer outcomes for both mothers and neonates in unplanned out-of-hospital births, with increased incidence of post-partum haemorrhage, perineal tears, delayed third stage of labour and need for neonatal resuscitation^5-9. Studies have reported obstetric complications in 11.7% of out-of-hospital births attended by Australian paramedics, with a neonatal death rate of 2.7%. Antenatal and intrapartum complications occurred in 27% of cases, and 22% of neonates had reduced Apgar scores^5,9. While data on the exact proportion of out-of-hospital births occurring in rural areas are limited, evidence suggests that a significant number of these cases take place in rural and remote settings, where access to timely obstetric care is restricted, thereby increasing the likelihood of obstetric emergencies^5,9.

Professional, societal and patient expectations mandate that paramedics possess not only clinical competence but also confidence in managing obstetric emergencies for optimal patient outcomes^3,5,10-12. However, empirical evidence indicates a notable discrepancy between these expectations and the reality of paramedics' confidence levels, as evidenced by qualitative data highlighting experiences of vulnerability, overwhelm, insufficient readiness and heightened stress during obstetric emergency responses^5,7,12. Despite these findings, there exists a dearth of research focusing on paramedics' confidence levels specifically within the realm of obstetric emergencies, along with an assessment of the factors influencing confidence and the ramifications of confidence levels on clinical proficiency, patient safety and mental wellbeing^5,7,13.

Confidence, defined as a dynamic mental attitude of trust or certainty, is influenced by various factors including clinical competency, hierarchical structures, emotions and professional experience¹¹. While historically, medical education has primarily focused on skill-based competency, recent attention has turned to understanding the role of confidence in facilitating or hindering clinical competency^11,14. Research is now beginning to acknowledge confidence as a phenomenon impacting clinicians' ability to execute essential skills, manage cognitive load, and optimise patient and team experiences^11,14,15. In clinical settings, the discrepancy between possessing necessary knowledge and lacking confidence can impede the implementation of critical skills and decision-making processes, potentially compromising individual contributions and team performance^11,16. Effective management of medical emergencies hinges on proportional confidence, cultivated through rigorous training and adequate clinical exposure^5,11,16. Acknowledging and addressing confidence levels is essential for clinicians and healthcare teams dealing with obstetric emergencies, as confidence strongly shapes decision-making, behaviours and team dynamics, fostering improved communication, clinical judgement and team cohesion¹¹. Conversely, misalignment between confidence and competence poses risks, with documented cases of overconfidence leading to unsafe practice, and lack of confidence inhibiting critical decision-making skills^11,14,16. Furthermore, confidence is a modifiable factor that may help mitigate paramedic ill-being, as lower confidence has been associated with increased vulnerability to mental health challenges, including stress, anxiety and burnout^11,17,18. Therefore, confidence should be viewed as a modifiable risk factor in preventing paramedic mental illness. This review aims to explore paramedics' confidence in managing prehospital obstetric emergencies, identify influencing factors, and examine the implications of confidence on patient and paramedic welfare.

Methods

Methodological framework and reporting

This scoping review adheres to the Joanna Briggs Institute methodology and the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews (PRISMA-ScR) guidelines (Supplementary figure 1). The protocol was not registered.

Eligibility criteria

For evidence to be included in the scoping review, articles must have met a pre-determined set of inclusion and exclusion criteria, outlined in Table 1.These were developed in line with the Population, Concept, and Context framework, which was unanimously agreed upon by all authors.

Search strategy

During January 2024 an early search using Google Scholar was carried out to identify initial articles and assess the breadth of available evidence. Subsequently, titles, abstracts and subject headings from these articles were used to construct a comprehensive search strategy for databases CINAHL (EBSCOhost), MEDLINE (Ovid), and SCOPUS (Supplementary table 1). These databases were chosen based on their extensive collection of international prehospital and paramedic literature, which was deemed crucial for addressing the research aim amid limited existing research. A hand search of relevant citations within reference lists was also conducted to identify additional papers that may been missed in the database searches.

The search utilised a combination of key terms and MeSH headings including emergency medical technician*, paramedic*, ambulance, EMT, confidence, obstetric, pregnancy complication(s), out of hospital birth(s). Terms were combined with the appropriate truncation symbols and Boolean operators, and were adapted for each database dependent on keywords and index terms (Supplementary table 1).

Evidence screening and selection

After conducting an initial search across databases including CINAHL Plus, Scopus and MEDLINE ALL, a total of 125 articles were identified and uploaded into EndNote, from which 33 duplicates were eliminated, resulting in 92 unique articles. Additionally, three articles were identified through manual literature search. Subsequent screening involved a thorough review of titles and abstracts by the first and second authors against the review’s inclusion criteria. Eighteen articles were selected for full-text review, with their citation details managed using JBI SUMARI. Both authors independently evaluated the full texts against the predefined inclusion and exclusion criteria. Any conflicts in screening and selection were resolved through discussion, with the primary author making the final decision based on objective criteria. Data extraction was also conducted independently by both authors to ensure accuracy and consistency. Ultimately, 13 articles met the criteria for inclusion in the scoping review. A comprehensive overview of the search and selection process is presented in the PRISMA-ScR diagram (Supplementary figure 1).

Data extraction

Data extraction was completed by both authors using a standardised data extraction template developed by the authors. This outlined specific details related to the study’s aim, participant characteristics and study design to ensure strict alignment with the inclusion criteria. An additional column outlining findings relevant to the study aim was used to draw key points from each of the studies (Table 2).

Data analysis and presentation of results

The data were carefully analysed in accordance with the methodological directives delineated by Peters and Marnie¹⁹. This structured approach involved extracting and combining data in a descriptive and logically structured manner, thereby facilitating the identification of key points relevant to the review’s objective (Table 2).

Results

This review included the following studies: Flanagan et al (2017, 2019)^7,8, Hill et al (2023)⁵, Kumar et al (2016)²⁰, Lenson and Mills (2018)²¹, McLelland et al (2013, 2015, 2016, 2017, 2018)^{9,13,16,22,23}, Persson et al (2019)¹², Schultz et al (2021)²⁴ and Vagle et al (2019)¹⁷. These studies were systematically analysed to assess paramedics' experiences, confidence levels and training in managing out-of-hospital births.

Demographics for search results

Most publications were from Australia (n=11) with the remaining from the US (n=1), Norway (n=1) and Sweden (n=1). The main methodology utilised was a retrospective data analysis of patient healthcare records (n=6), followed by qualitative methods (n=4), quasi-experimental (n=2) and narrative enquiry (n=1).

Education and training

A recent Australian inquiry uncovered significant deficiencies in obstetric education and training within the paramedic community⁵. Of the 14 paramedics surveyed, almost 80% reported gaps in their exposure to obstetric training during the initiation of their paramedic induction⁵. Six participants recalled receiving no obstetric training during this pivotal phase, while an additional five indicated a lack of ongoing education in obstetrics⁵. Despite an average service tenure of 7.5 years, paramedics recounted receiving minimal obstetric training beyond their initial induction, with estimates ranging from none to 3 days⁵. One participant likened their readiness to identify obstetric complications to what could be expected of a basic first aider trained to assist with an uncomplicated childbirth⁵. These findings highlight a concerning scarcity and a perceived inadequacy of obstetric training opportunities, resulting in reservations among paramedics regarding their knowledge base and skill proficiency.

Given the scarcity of Australian research, it is crucial to consider international studies that also outline how inadequate training exacerbates low confidence and imposes a significant psychological burden on paramedics tasked with handling obstetric emergencies^12,17. This was pronounced in a qualitative investigation conducted in Norway with 12 participants who provided valuable insights into their obstetric training experiences¹⁷. For some participants, their sole exposure to obstetric education consisted of a single 1-hour lecture¹⁷. This minimal exposure left many feeling ill-prepared and overwhelmed by the complexities of managing obstetric emergencies¹⁷. One participant described feeling that women unable to reach the hospital in time for delivery were vulnerable to unpredictable outcomes, colloquially described by the participant as being ‘at the mercy of nature’¹⁷. Participants consistently called for enhanced obstetric training, yet many had to rely on their own initiative and networking to try secure training¹⁷. The study revealed that numerous participants sought additional obstetric education following traumatic obstetric cases or personal experiences, but attempts to arrange supplementary clinical training in birthing facilities often encountered logistical challenges, necessitating reliance on personal connections or acts of goodwill to secure placements¹⁷. However, some participants, particularly the male paramedics, recounted instances of hostility, discrimination and social isolation during their interactions in birthing environments¹⁷. Frustration was also voiced at the limited opportunities for hands-on training, with one participant describing the importance of practical training in obstetrics as akin to that required for practising for resuscitation¹⁷. Similar frustrations were echoed in an Australian study, with one participant recalling a conversation with her paramedic educator about the inadequate time allocated to obstetrics training⁵. The educator responded, ‘It's quite rare we go to it’, indicating that infrequency of attended obstetric cases justifies an absence in training⁵. The participant reflected that this rarity was precisely why more time should be devoted to such training⁵.

Despite repeated recommendations that paramedic training include regular placements in hospital settings to increase exposure to normal obstetric events and improve identification of obstetric complications, this approach faces several challenges^7,12,17. The value of obstetric clinical placements for paramedics has proven inconsistent due to access difficulties and high demand from medical, nursing and midwifery students, making this solution for skills training unviable^7,20,21,25. Alternatively, the literature supports implementing regular interprofessional obstetric training programs that offer high-fidelity training outside hospital settings^13,20,21,26. An Australian study evaluating the psychomotor skills of 29 paramedic students during simulated obstetric emergencies found that hands-on experience was confidence-building, and reflective opportunities were invaluable for learning²¹. Likewise, McLelland et al (2017) found that effective simulation training significantly increases paramedics' confidence in achieving successful birth outcomes by 40%¹³.

A larger study with 73 participants (paramedics and midwives) evaluated the efficacy of high-fidelity, in-situ simulation workshops focused on home birth practices²⁰. The findings aligned with those reported by Lenson and Mills that high-fidelity workshops not only bolstered paramedics' preparedness for obstetric emergencies but also elicited positive behavioural shifts and fostered enhanced interprofessional rapport and knowledge transfer^20,21. Participants across these studies reported heightened confidence and empowerment after their engagement with simulation scenarios, increased situational awareness and strengthened team cohesion between paramedics and midwives^20,21,26. These findings are noteworthy, given the reported interprofessional tensions between paramedics and midwives, which act to exacerbate the insecurity of paramedics navigating and transferring care during obstetric crises¹⁷.

Despite the potential antiquation of several studies examining the link between education, training and paramedic confidence in managing obstetric emergencies due to their pre-dating the implementation of paramedic registration and the adoption of graduate entry pathways within the profession, recent literature (post-2018) highlights consistent findings of low confidence levels attributed to ongoing inadequacies in education and training^5,10. A 2023 survey of 264 Australian paramedics reported prehospital obstetric care knowledge as an area of concern, regardless of the diverse clinical scopes of practice represented among the participants¹⁰. Given median attendance of only two births over their careers, paramedics lack substantial exposure to out-of-hospital obstetric emergencies, emphasising the need for ongoing, high-calibre training to enhance confidence and competence¹⁰. Respondents emphasised the importance of consistent in-service education and training to strengthen confidence and ensure the retention of skills¹⁰.

Impact on patient safety

The limited number of obstetric emergencies encountered by paramedics contributes to skills deterioration, diminished confidence and potential patient clinical safety risks^7,9,27. Several studies reveal instances where paramedics either administered treatment unnecessarily or failed to administer indicated treatment^7,9,27. For instance, fundal massage, an essential practice for preventing postpartum haemorrhage, was found in certain studies to be initiated prematurely^7,9. Prematurely initiating fundal massage before the completion of the third stage of labour poses life-threatening risks such as placental separation and excessive maternal blood loss, making it contraindicated⁷. In one study, 76 women received fundal massage initiated by paramedics, although only 21 of these were documented to have completed the third stage of labour⁹. This mismanagement was attributed to inadequate clinical knowledge, limited exposure, cognitive overload and high paramedic stress levels⁹.

The discrepancy between recommended care and actual implementation by paramedics in obstetric emergencies is a recurring theme in literature. Current international guidelines for modified active management of third stage labour include the administration of uterotonic medication such as oxytocin to prevent postpartum haemorrhage^24,27-29. However, Schultz et al (2021) found that paramedics withheld modified active management of third stage labour in 17.4% of cases, with half of these lacking justification, which raises concerns about paramedic knowledge and competency²⁴. Inadequate and inconsistent patient documentation also poses significant clinical risks, hindering safe decision-making, continuity of care and communication among multidisciplinary teams^28-30. Inconsistent documentation during out-of-hospital births, particularly regarding neonatal vital signs and Apgar scores, is also reported^7,9. Flanagan et al (2017) found that the requirements for separate documentation for newborns were adhered to in only 66.8% of cases, and continuation of vital sign documentation after the initial Apgar score was recorded in only 60% of cases⁷. Given the higher rates of complications in out-of-hospital births, proper identification and timely management of neonatal issues are crucial, necessitating improved neonatal knowledge and assessment skills among paramedics^7,9.

A Swedish qualitative study by Persson et al (2019) unveiled a prevailing theme of apprehension and insufficient confidence among paramedics in handling neonatal patients¹². Paramedics often found themselves overwhelmed when confronted with the sudden responsibility of attending to both the mother and the newborn, a sentiment exacerbated by feelings of unpreparedness attributable to limited clinical exposure and their insufficient training¹². Two additional Australian studies also highlighted concerns regarding neonatal management, emphasising themes of uncertainty and limited confidence, particularly in challenging scenarios such as breech births where the potential risk of limb entrapment posed cognitive barriers to feeling confident in managing emergencies^5,21. Another study highlighted the significance of the historically limited availability of monitoring equipment for neonates within ambulance services, such as paediatric oxygen saturation probes and temperature measurement devices, which further compounded the challenges faced by paramedics in managing neonatal emergencies⁷. In the absence of adequate equipment and support, paramedics encounter considerable obstacles in confidently identifying and addressing neonatal complications, thereby posing significant risks to patient safety^7,12,17. Furthermore, it was suggested that this uncertainty and apprehension may contribute to incomplete documentation practices, as paramedics might be hesitant to conduct comprehensive assessments of neonates⁵. These findings highlight critical deficiencies in patient care and safety.

Patient experience and maternal psychological wellbeing

Given the apprehension and fear reported by paramedics in managing out-of-hospital births, and the acknowledged impact of attending clinicians on women's birth experiences, it is imperative to explore how paramedic confidence influences women's childbirth experiences¹⁰. Although evidence regarding women's experiences of out-of-hospital births in paramedic care is extremely limited, an Australian narrative inquiry study offers some valuable insights¹⁰. Interviews with 22 women elicited diverse experiences ranging from positive to negative interactions¹⁰. Positive experiences were underpinned by stories of competent paramedics who conveyed clinical proficiency while providing reassurance and effective communication¹⁰. Participants recalled the importance of a calm demeanour, clear communication and reassurance as fundamental to a positive birth experience¹⁰. Conversely, negative experiences stemmed from concerns about clinical incompetence, poor communication, perceived disrespect and lack of empathy¹⁰. Instances of feeling violated, disrespected, yelled at, having legs held apart without explanation and failure to obtain consent were recounted as extremely traumatic by some women¹⁰. One woman recounted the attending paramedic admitting uncertainty in managing the birth and instead prioritised immediate transport to the hospital¹⁰. Such encounters are not isolated occurrences, as evidenced by one participant in another Australian study admitting they would advise a woman to ‘close her legs’ until arriving at the hospital if birth was imminent during ambulance transport¹⁰.

Psychological impact on paramedics

While attending an imminent birth may be perceived as a pinnacle of one's career and a moment of anticipation, the realisation of joy and fulfillment often occurs retrospectively, upon confirmation of the wellbeing of both mother and child¹². Qualitative insights from paramedics attending obstetric emergencies as reported by the Swedish study by Persson et al (2019) reveal that the initial call to attend to an obstetric emergency evokes profound stress, anxiety and apprehension, primarily attributable to the notably low confidence paramedics harbour in their ability to manage even a 'normal’, ‘uncomplicated birth'¹². This deficit in confidence was demonstrated to undermine paramedics' sense of safety and wellbeing when responding to out-of-hospital births⁹. In this study, paramedics articulated feelings of significant helplessness and frustration in managing obstetric emergencies¹². They described experiencing immense pressure to remain clinically confident and competent as they felt these directly influenced their own sense of safety and subsequent ability to deliver optimal patient care¹².

Australian and Norwegian studies highlighted the profound consequences of diminished confidence in managing out-of-hospital births^5,17. Common themes of low confidence fuelling feelings of isolation and helplessness were prevalent and exacerbated by logistical and environmental challenges^5,17. Factors such as rurality, extended distances to definitive care, insufficient clinical support, poor mobile phone signal and limited staffing were found to significantly contribute to paramedic stress during out-of-hospital birth management^5,17. Participants in the Norwegian study recounted the need to often improvise their clinical setting to effectively address obstetric emergencies¹⁷. This involved innovative measures such as repurposing dining tables into makeshift resuscitation areas or converting loungerooms into makeshift birth suites¹⁷. Participants from both studies highlighted additional rural challenges, such as extended transportation times over substandard roads, ferry crossings over rivers and minimal support staff resources, all of which exacerbated the difficulties encountered by paramedics^5,17. These circumstances expose paramedics to environmental hazards and accentuate the inherent unpredictability of their working environments^5,17.

The psychological implications of paramedic confidence in managing out-of-hospital births are also shown to be influenced by the experience level of their partners, with paramedics reporting greater reassurance and confidence when partnered with experienced colleagues^5,17. Conversely, attending an out-of-hospital birth with an inexperienced partner was demonstrated to exacerbate feelings of anxiety and stress, impeding effective management of the situation¹⁷. Instances of inexperienced partners becoming overwhelmed and panicking during emergencies highlight the critical importance of having competent and experienced colleagues in such situations¹⁷. Notably, the burden of addressing both clinical and logistical challenges weighs heavily on paramedics, exacerbating their anxiety and stress levels, and potentially leading to poorer psychological outcomes^5,17. However, amidst these challenges, paramedics have highlighted the value of being able to follow up on patient outcomes in hospital settings¹². This not only provides closure on the case but also serves as a reflective learning tool for future events^12,17.

Discussion

This review found that paramedic training and education significantly impact paramedic confidence in managing obstetric emergencies, which in turn may affect both maternal wellbeing and paramedics' own mental health. However, due to the recency of paramedic registration in Australia in 2018 and the extremely limited evidence available beyond this timeframe, it is unclear whether registration itself has influenced paramedic confidence in obstetric care.

The relationship between confidence and its impact on clinical competency is complex. Confidence can influence clinical competency, predispose to clinical risks and facilitate either positive or negative patient experiences, thus significantly affecting paramedics' mental health outcomes during obstetric cases¹¹. Additionally, paramedics' confidence in managing obstetric emergencies is heavily influenced by their education and training, which plays a critical role in contributing to or alleviating cognitive overload^5,11,17. Paramedics who lack confidence and adequate hands-on training may rely solely on procedural memory or feel overwhelmed and helpless when handling unfamiliar emergencies, potentially compromising patient safety and comfort^11,12.

Subsequently, it can be hypothesised that paramedics experiencing cognitive overload and lacking confidence may struggle to create a safe and reassuring environment for patients, which in turn affects the patient’s psychology and trust in the attending clinician. Gottlieb et al (2022) supports this hypothesis, suggesting that clinicians who possess an appropriate balance of confidence and competence are better equipped to adapt their skills without succumbing to cognitive overload, thereby enhancing the patient experience¹¹. Findings from an investigative interview study conducted by Ahl and Nyström (2012) also support the notion that diminished clinician confidence may compromise patients' sense of safety under paramedic care. The research indicates that patients exhibit greater trust in clinicians who maintain composure and provide reassurance, particularly in emergency situations³¹.

Prior to the introduction of paramedic registration in Australia, the title of 'paramedic' was not legally protected, resulting in a lack of standardised, mandatory training across the country²⁵. Consequently, there was no uniformity in the education and training of paramedics, which may account for the historically low confidence levels observed among paramedics when managing obstetric emergencies²⁵. However, since the establishment of paramedic registration in Australia in 2018, entry into the paramedicine profession now typically necessitates the completion of a university degree program accredited for paramedic education²⁵. These programs are meticulously designed to impart the essential knowledge and skills required for providing emergency medical care in diverse settings, thereby ensuring that paramedics meet a consistent academic benchmark for education and training^21,25. However, despite the rigorous training provided by these programs, there are clear persistent challenges in ensuring that paramedics are adequately prepared to manage obstetric emergencies effectively^5,7,10. Despite the limited research in this field, there is clear evidence demonstrating an ongoing pervasive culture of fear, low confidence and critical knowledge gaps among paramedics when responding to obstetric cases^5,7,17. There remains a critical need for comprehensive obstetric education and training programs tailored to paramedics' needs, including regular high-fidelity simulation training and interprofessional collaboration opportunities^18,21,26. Additionally, addressing barriers to accessing obstetric placements and improving the quality of hands-on training can enhance paramedics' confidence and competency in managing obstetric emergencies^7,21,26.

Childbirth represents one of the most pivotal events in a woman's life, characterised by its profound individuality and susceptibility to a wide range of influencing factors^9,13,32,33. The quality of maternal psychological wellbeing during the birth experience is significantly shaped by factors such as feeling supported, having trust in the attending clinicians, and a birth process tailored to the woman's cultural, social and emotional needs¹⁰. Furthermore, the birth experience significantly influences a woman's self-esteem regarding motherhood and her perceived capability in fulfilling the role of a mother^10,32. This is significant considering perinatal anxiety and depression pose considerable public health concerns, affecting one in three and one in four women, respectively, with maternal suicide accounting for 10% of all maternal deaths^10,34. When maternal expectations of childbirth are not aligned with the actual experience, particularly when there is a perceived loss of autonomy and a sense of being ignored or disregarded, it can lead to psychological trauma^10,31,34-36. Women who undergo unplanned out-of-hospital births or encounter unexpected complications during home births are especially vulnerable to maternal trauma given the abrupt disruption to their envisioned birth plan¹⁰. The response of attending paramedics in such situations has a significant influence on maternal psychology¹⁰. Despite paramedics aspiring to exude confidence and control during emergencies, childbirth emerges as a clinical realm inhibited by diminished confidence, which must be addressed to ensure positive and safe patient experiences^5,6,10,12,17.

Clinician confidence exerts a dual influence, significantly affecting both patient psychological wellbeing and the clinician's own mental health^11,36-40. Although not specific to paramedics or healthcare professionals, extensive research highlights the significant impacts of diminished confidence on mental wellbeing in general. Studies consistently show that individuals with low self-assurance are at nearly a six times higher risk of developing depression and four times more likely to experience depressive symptoms compared to their more confident counterparts^18,36,37. Stressors such as diminished confidence, feelings of helplessness and lack of support have been identified by multiple studies as significant influencers of paramedics' physical and mental wellbeing^18,36-40. Prevalence rates of anxiety, depression and post-traumatic stress disorder among paramedics range from 10% to 27%, markedly exceeding those observed in the general population³⁷. Alarmingly, paramedic students report even higher stress levels due to low-confidence experiences during training and insufficient clinical exposure to bolster confidence, with studies indicating anxiety prevalence at 24%, depression at 28%, and post-traumatic stress disorder ranging between 16.8% and 20.2%^40-42. Given paramedics' predisposition to mental health concerns due to the inherently 'traumatic' and 'high stress' nature of their role, it is critical to contemplate the implications of confidence beyond its influence on clinical competence and recognise it as a modifiable risk factor contributing to paramedic mental health issues¹⁸. Therefore, prioritising the mental health and wellbeing of paramedics through post-event debriefing, supportive supervision and access to mental health resources is imperative^12,17,18. Additionally, addressing systemic issues such as inadequate resources and logistical challenges can mitigate paramedics' stress and enhance their confidence in managing obstetric emergencies^5,17.

While this review did not specifically focus on rural areas due to the scarcity of evidence on this topic, several reviewed studies highlight broader factors influencing paramedic confidence, which may have relevance in rural and remote contexts. Rural and remote areas often face unique challenges, including longer response times, limited access to specialised equipment or medical facilities, and fewer opportunities for training and professional development⁵. These factors may contribute to differences in paramedic confidence when managing obstetric emergencies, although further research is needed to explore this relationship directly⁵. As obstetric care becomes increasingly centralised, rural communities are experiencing higher rates of home births, further highlighting the importance of understanding how resource availability and geographic isolation impact paramedic preparedness³. Future research should examine the intersection of rurality, resource access and paramedic confidence to inform policies and training strategies aimed at improving obstetric emergency care across diverse settings.

Moving forward, it is essential to continue exploring the multifaceted relationship between confidence and competence in obstetric emergency management. While confidence can influence performance, it does not inherently equate to competence, and overconfidence without adequate skills may pose clinical risks. Therefore, both confidence and competence are necessary for improving paramedic management of obstetric emergencies. Future research should focus on evaluating the effectiveness of educational interventions, training programs and support systems in enhancing not only paramedics' confidence but also their clinical proficiency and decision-making abilities. Additionally, exploring innovative approaches, such as high-fidelity and virtual reality simulation training, can provide paramedics with opportunities to refine their skills and confidence simultaneously, particularly in resource-limited settings^21,25. Addressing deficits in both areas is crucial for improving obstetric emergency management, enhancing patient safety and outcomes, and promoting the psychological wellbeing of paramedics^5,7. By prioritising comprehensive education, training and support systems, healthcare systems can empower paramedics to provide both confident and competent care during obstetric emergencies, ultimately improving maternal and neonatal health outcomes^5,7,21,25.

Limitations

The limitations of this review primarily stem from the dearth of available literature for analysis, likely attributable to the relatively recent establishment of paramedicine as a recognised profession. Consequently, our analysis had to rely on literature pre-dating the introduction of paramedic registration in Australia during 2018, thus potentially limiting the applicability of results to the present status of registered paramedics. Despite initial efforts to source literature that was Australian based, the scant results forced us to include parallel international studies in the review to comprehensively address our research objectives. The literature with a specific focus on rurality and the implication of poorer paramedic confidence in rural areas is largely absent and represents a critical area of future research given the additional stressors of rural environments. Another notable limitation is that 8 of the 13 included papers were authored by two individuals, raising concerns about potential author biases. While we acknowledge these inherent challenges, this scoping study has identified a significant gap in current research on the chosen topic, emphasising that further investigation is required to develop knowledge of paramedic confidence in managing obstetric emergencies.

Conclusion

Paramedic education and training play a critical role in shaping confidence and competence in managing obstetric emergencies. While confidence is an essential factor influencing clinical performance, it does not necessarily equate to competence. Overconfidence without adequate skills may pose risks, whereas a lack of confidence can hinder effective decision-making and compromise patient outcomes. Achieving an appropriate balance between confidence and competence is fundamental to improving paramedic management of obstetric cases.

The introduction of paramedic registration in Australia in 2018 marked a significant shift in standardising paramedic education and training; however, little is known about how this has impacted paramedic preparedness and confidence attending obstetric emergencies. Existing evidence, both prior to and following its inception, indicates that many paramedics experience low confidence and significant knowledge gaps in this domain, which may contribute to cognitive overload, heightened stress levels and potential compromises in patient safety. Addressing these challenges requires comprehensive obstetric education and training tailored to paramedics’ needs, including hands-on experience, high-fidelity simulation training and interprofessional collaboration.

Clinician confidence not only affects patient care but also has profound implications for paramedic mental health. Low confidence has been associated with increased stress, anxiety and burnout, which are prevalent among paramedics at higher rates than the general population. Given the inherently high-stress nature of paramedicine, it is crucial to consider confidence as a modifiable factor influencing mental wellbeing. Enhancing support systems, debriefing opportunities and access to mental health resources is essential in mitigating these risks.

With the increasing centralisation of obstetric care and rising home birth rates in rural areas, future research must explore the intersection of paramedic confidence, resource availability and geographic isolation to inform targeted training and policy interventions. Moving forward, research should continue to investigate the effectiveness of educational interventions, training programs and support systems in enhancing both paramedic confidence and clinical proficiency. Innovative training approaches, such as high-fidelity simulation and virtual reality, offer promising opportunities to strengthen both skill acquisition and confidence in obstetric emergency management. Additionally, future research should strive to quantify the impact of paramedic registration on confidence levels and discern the specific factors directly influencing paramedic confidence during the management of obstetric emergencies. Continued efforts to bridge the gap between confidence and clinical competencies are essential for ensuring safe and effective healthcare delivery in out-of-hospital obstetric settings, with focused attention on the unique needs of rural and remote communities. By addressing deficits in both confidence and competence, healthcare systems can empower paramedics to provide high-quality, compassionate care during obstetric emergencies, ultimately improving maternal and neonatal health outcomes.

Acknowledgements

The authors extend their gratitude to Associate Professor Rachel Rossiter for her invaluable assistance in editing and academic guidance. Special thanks are due to Lorraine Rose of Charles Sturt University for her support in devising effective search strategies and for her ongoing academic guidance throughout the process

Funding

No funding was received for this research.

Conflicts of interest

The authors declare no conflicts of interest.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials.