Out-of-hospital birth training, experience and confidence of Australian rural volunteer ambulance officers

Introduction: Unplanned out-of-hospital births represent less than one percent of ambulance requests for assistance. However, these callouts have a high risk of life-threatening complications, which are particularly complex in rural or remote settings with limited accessibility to specialist care support. Many community hospitals no longer provide obstetrics care and birth parents must travel to larger regional or metropolitan hospitals for assistance. Increased travel time may increase the risk of unplanned-out-of-hospital birth and/or complications such as postpartum haemorrhage or neonatal mortality. Rural volunteer ambulance officers (VAOs) are an integral component of Australia’s healthcare system, especially in regional and remote areas. Although VAO response to unplanned out-of-hospital birth may be considered rare compared to calls to other case types, provision of adequate care is paramount in these potentially high-risk situations.
Aims: This research investigates Australian rural VAOs’ perceptions of their training, experience, and confidence regarding unplanned out-of-hospital birth and planned homebirth with obstetric emergencies where ambulance assistance is required.
Methods: Semi-structured interviews and focus groups were undertaken from late 2021 to mid-2023 via telephone or online videoconference. Sessions were audio-recorded and transcribed verbatim. Data were analysed and coded into themes using Braun and Clarkes six-step process for semantic coding and reflexive thematic analysis.
Results: Twenty-eight participants were interviewed from six Australian states and territories, all of whom worked in rural and remote Australia. Ten participants were male, 17 female and one was male-adjacent, with length of VAO experience ranging from 3 months to 29 years. Participants came from seven jurisdictional ambulance services.
Four themes emerged from analysis:
(1) Lack of education and exposure to birth resulted in low confidence. Most participants reported significant anxiety attending obstetric callouts, and explained underutilisation of specific obstetric and neonatal skills meant skills decay was an issue;
(2) Limitations were discussed regarding VAO scope of practice and accessing medical equipment specifically required for birthing and neonates which could impact patient care;
(3) Logistical and communication difficulties were discussed. Vast distances to definitive care, potentially limited backup during emergencies, and potential unavailability of aeromedical retrieval increased perceived complexity of cases. Telecommunication ‘black holes’ created a sense of further isolation for VAOs requiring support from senior clinicians;
(4) Lastly, there was a perception that many members of the general public were unaware VAOs often staffed the local ambulance and expected VAOs to have the same scope of practice as a registered paramedic. Furthermore, VAOs can attend friends and family in an emergency, potentially creating psychological trauma.
Conclusion: VAOs report being uncomfortable attending unplanned out-of-hospital births and obstetric emergencies, perceiving they have limited ability to manage complications. Backup from a registered paramedic is dependent on availability, and telecommunications are not always reliable in rural areas for online clinical advice and support. Given the distances to definitive care in regional Australia, this has serious implications for patient safety. Continued VAO education is essential for risk reduction in out-of-hospital births.