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

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

the literature

Jillian Ireland, Helen Bryers, Edwin van Teijlingen, Vanora Hundley, Jane Farmer, Fiona Harris,

Janet Tucker, Alice Kiger & Jan Caldow

Accepted for publication 23 January 2007

Jillian Ireland BA MSc RM RN DipPsych

Lecturer in Midwifery, School of Nursing &

Midwifery, The Robert Gordon University,

Aberdeen, UK

Helen Bryers BA RN RM MM

Head of Midwifery NHS Highland, NHS

Highland, Inverness, UK

Edwin van Teijlingen MA MEd PhD

Reader in Public Health, Department of

Public Health, University of Aberdeen,

Aberdeen UK

Vanora Hundley MSc PhD BN RN RN RM

Honorary Senior Lecturer, Department of

Nursing & Midwifery, University of Stirling,

Stirling, UK

Jane Farmer MA PhD

Professor, Centre for Rural Health, UHI

Millennium Institute, Inverness, UK

Fiona Harris MA PhD

Research Fellow, Community Health

Sciences – General Practice Section,

University of Edinburgh, Edinburgh, UK

Janet Tucker BSc PhD C Ed MPH

Senior Researcher, Dugald Baird Centre for

Research on Women’s Health, University of

Aberdeen, Aberdeen, UK

Alice Kiger MA MSc PhD RN DipN RNT

Director, Centre for Advanced Studies in

Nursing, University of Aberdeen, Aberdeen,

UK

Jan Caldow MSc RN

Research Fellow, Department of General

Practice & Primary Care, University of

Aberdeen, Aberdeen, UK

Correspondence to Edwin van Teijlingen:

e-mail: [email protected]

IRELAND J. , BRYERS H., VAN TEIJLINGEN E. , HUNDLEY V. , FARMER J. ,IRELAND J. , BRYERS H. , VAN TEIJLINGEN E. , HUNDLEY V. , FARMER J. ,

HARRIS F. , TUCKER J. , KIGER A. & CALDOW J. (2007)HARRIS F. , TUCKER J. , KIGER A. & CALDOW J. (2007) Competencies and skills

for remote and rural maternity care: a review of the literature. Journal of Advanced

Nursing 58(2), 105–115

doi: 10.1111/j.1365-2648.2007.04246.x

AbstractTitle. 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’, ‘compe-

tencies’, 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 compe-

tencies 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 port-

folios. More research is needed on the levels of skills and competencies required for

maternity care professionals practising in remote and rural areas.

Keywords: ambulance, competence, competency, literature review, midwifery

education, skills

REVIEW PAPERJAN

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 105

Introduction

The trend in maternity care provision in many developed

countries has been one of falling birth rates and central-

ization. The latter is specifically noticeable in the drive

towards fewer centres for specialist care, which has

impacted upon maternity services in remote and rural

areas (e.g. Farmer et al. 2003). For example in Scotland,

there are proposals to centralize many services, such as

emergency departments and maternity care, by removing

these from smaller hospitals (Christie 2005, p. 924). This

has created particular difficulties, such as reduced patient

choice, quality of care, safety and sustainability of

maternity services, lack of trained staff, and professional

development [Scottish Executive Health Department

(SEHD) 2002b, Fahey & Monaghan 2005]. Remote and

rural maternity care is characterized by generalists

providing care locally and the need for patients to travel

distances to specialist care facilities. As the policy

document A Framework for Maternity Services in Scotland

(SEHD 2001, p. 25) acknowledged, ‘equity and access to

acute services in remote and rural areas is difficult’. A

realistic approach must be taken to provide, as far as is

reasonably practicable, a service that is woman and

family-centred and takes account of choice, safety and

availability of transport in routine and emergency situa-

tions.

This review of remote and rural maternity care in

Scotland was commissioned with this specific population

in mind. In Scotland, the policy report produced by

Expert Group on Acute Maternity Services (EGAMS)

reiterated that there is no such thing as zero risk for

women who are pregnant or giving birth, and that this

must be explicit in developing local strategies and practice

in remote and rural areas (SEHD 2002b). The Temple

Report (SEHD 2002a) recommended extending the effect-

ive use of managed clinical networks and establishing

remote and rural strategies for staff development. This

should include strategies for staff based in rural areas to

spend time in acute units on regular basis. Moreover,

Baird et al. (1996, pp. 223–226) suggested that 30% of

low-risk women required some kind of medical/obstetric

support, and therefore organized medical support is

required in the rural setting.

In the light of many of these issues raised above the Scottish

Government established the Remote and Rural Areas

Resource Initiative (RARARI) from April 2000 with a budget

of £8 million spread over four financial years. RARARI

aimed ‘to secure sustainable improvements in rural health

care’ (Scottish Executive 2003).

Definitions of ‘remote’ and ‘rural’

A confusing variety of definitions of ‘remote and rural’

exists (Farmer et al. 2001, Nuttall et al. 2002) from those

based on population-density (Williams et al. 1998) to

classifications based on travel time to key services (Weinert

& Boik 1995, Hays et al. 1994). Scotland has five identified

types of rural area based on (1) degree of remoteness; (2)

population density; (3) settlement patterns; (4) demographic

profiles; and (5) economic profiles (Scottish Office 1996).

The Scottish Executive (2005a) defined rural as ‘settlements

with a population of <3000 inhabitants’. Similar classifi-

cation problems were found in, for example, the United

States of America (USA) where there are two official

definitions of rurality in use: one based on population

density, relationship to cities, and population size and

another based on population size and integration with large

cities (Ricketts et al. 1998, p. 5). In this review, we adopted

the pragmatic approach, namely that the definition should

best meet the purposes of the research question (Hoggart

1990, Rousseau 1995), and hence we accepted any defini-

tion of rural, i.e. as used by the authors in the publications

we reviewed.

Aims

This literature review explores and summarizes the issues and

arguments surrounding remote and rural maternity care with

particular reference to continuous professional development

(CPD) skills, competencies and training. CPD is maintaining

and updating skills and knowledge, therefore our review

branched into the wider area of defining skills and compe-

tencies, related training and ways of verifying CPD achieve-

ment. Our aim was twofold: (1) to have the greatest coverage

of these issues related to maternity care provision in remote

and rural areas in the developed world; and (2) to inform a

national research study into sustainable maternity care in

Scotland.

Methods

The literature review included a comprehensive search of

both published and so-called grey literature in the English

language dating from 1995 to October 2006. A range of

electronic databases (Medline; SSCI; CINAHL; EMBASE;

MIDIRS; Cochrane Review, British Nursing Index) was

searched as well as the Royal College of Midwives (RCM)

Library. These databases were searched using key words

including: ‘maternal health services’, ‘maternity’, ‘midwifery’,

‘midwifery-led care’, ‘obstetrics’, ‘rural’, ‘remote’, ‘health

J. Ireland et al.

106 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

services accessibility’, ‘professional competence’ and ‘skill’.

Where relevant references were found these were obtained.

We extended our search using article reference lists, and

bibliographies of books and reports. Relevant academic and

practitioners’ journals were hand searched (Table 1).

National policy documents and local health board action

plans were included along with journals previously covered

by Bryers et al. (2001).

Other strategies for identifying ongoing studies and

information included approaching experts in Scotland and

requesting information via several email discussion

groups (e.g. [email protected]; sociology-

[email protected]) and electronic newsletters (e.g.

obcnews web address: http://[email protected]). Articles

were excluded for the following reasons: no evidence was

provided for statements made, rural issues could not be

separated from general findings; the results of a study had

been reported in an article already included in the review.

Six hundred and fifty-five papers and reports from the

period 1995–2006 were retrieved and 114 satisfied the

inclusion criteria, many were discarded on reading of

the full text.

Results

The results are presented under three main headings: com-

petencies, education and training and assessment of clinical

risk.

Competencies for remote and rural practice

Our review of the literature, in line with the findings of Storey

et al. (2002), revealed no common approach to, or agreed

definition of, competence and competency. Furthermore, we

found no research-based information relating to competence

of healthcare providers in remote and rural settings.

The terminology surrounding competence is ill-defined

(Girot 1993) and hence ‘ambiguous and confusing’

(McMullen et al. 2003, p. 285). However, three common

themes are reflected in existing definitions:

• knowledge, understanding and judgement;

• a range of skills: cognitive, technical or psychomotor, and

interpersonal;

• a range of personal attributes (International Council of

Nurses 2001).

Nicholls and Webb (2006, p. 415) found that the term

competence is ‘often used to describe fitness to practice’.

Hence, the United Kingdom (UK) Nursing & Midwifery

Council (NMC) requires that competent practice involves

possessing ‘the knowledge, skills and abilities required for

lawful, safe and effective practice without direct supervi-

sion’ (NMC News 2003a, p. 13) while a ‘lack of compet-

ence’ is

A lack of knowledge, skill or judgement, which may be accom-

panied by a negative attitude. This is of such a nature or extent that

the nurse, midwife or health visitor is unfit to practice, and that

such concerns having been drawn to the attention of the practi-

tioner, he or she has either undergone training and supervision but

has failed to make the required improvements to practice, or has

refused to undergo further training or supervision. (NMC News

2003b, p. 6)

Competence includes not only appropriate skills and sup-

porting knowledge, but also appropriate values, referred to as

‘attitudes’ within nursing and midwifery. Although ‘skills’

and ‘competencies’ are often used interchangeably, compet-

ence signifies ‘not only the performance of a task, but also the

underlying knowledge and attitudes’ (Duffield 1991, p. 56).

Others have made a further distinction between competence

and competency (Manley & Garbett 2000). Competence is

job related, being a description of an action, behaviour or

outcome that a person should demonstrate in their perfor-

mance. Competency is person-orientated, referring to the

person’s underlying characteristics and qualities that lead to

an effective performance in a job (McMullen et al. 2003,

p. 285). Thus, competence is ability to perform aspects of the

job, while competency is behaviour underpinning the per-

formance (Woodruffe 1993). Some competence will be

common across disciplines, ‘but the level of proficiency

required to carry out the task may vary’ (Storey et al. 2002,

p. 1).

Measuring competency

In midwifery, ‘competencies’ are seen as the ‘basic knowledge

skills and behaviours required of a midwife to practice safely

in any setting. They answer the question: ‘What does a

midwife do? and are evidence-based’ (Fullerton & Thompson

2005). However, it can form a framework of practical mea-

Table 1 Hand-searched journals for this review

Birth British Journal of Midwifery

BJOG* Journal of Advanced Nursing

Midwifery Journal of Obstetric and Gynecologic

and Neonatal Nursing

The Lancet Journal of Nursing Management

Practising Midwife Professional Care Mother and Child

British Medical Journal Midwives/RCM* Midwives Journal

*BJOG, British Journal of Obstetrics and Gynaecology; RCM, Royal

College of Midwives.

JAN: REVIEW PAPER Competencies and skills for remote and rural maternity care


surable skills as demonstrated in the EGAMS Report (SEHD

2002b) core competencies for staff working in Community

Maternity Units (CMU) or low-risk settings. These compe-

tencies relate to good practice, maintaining patient safety and

clinical governance (SEHD 2002b). As with the ICM (2002)

‘basics’ list, supporting normal labour and childbirth is

identified as central to the provision of a quality maternity

service. There is a view, however, that a competency-based

approach might run the risk of returning to task orientation

(Anderson 1999, World Health Organization 2001) rather

than a more holistic approach.

Once achieved, competence must be maintained. In the

UK the NMC News (2003a) and General Medical Council

(GMC 2003) require practitioners to provide documentary

evidence of their efforts to maintain and develop ‘their

professional knowledge and competence’. A focus-group

study of Australian rural midwives showed support for a

UK-style mandatory CPD system (Fahey & Monaghan

2005, p. 6). The terms profile and portfolio are used

interchangeably to describe evidence of academic and/or

professional credibility. However, portfolios ‘cannot guar-

antee a change in performance’ (Hogston 1993, p. 167), and

there is little evidence of their effectiveness (McMullen et al.

2003).

In summary, competence is ability to perform aspects of

the job, while competency is behaviour underpinning the

performance, whilst midwifery ‘competencies’ are seen as the

basic knowledge skills and behaviours required of a midwife

to practice safely in any setting.

Education, training and CPD for remote and rural practice

Studies indicate the importance of early exposure of medical

students to rural practice (Rolfe et al. 1995, Wang 2002,

p. 97) and, conversely, that training ‘wholly in consultant units

may make them (practitioners) fearful of community-based

obstetrics’ (Baird et al. 1996, p. 226). This may affect

recruitment to remote and rural areas and also practitioners’

attitudes and practice. Caudle et al. (1995) argued that

specialist medical training may be instrumental in re-estab-

lishing an obstetric service in rural areas.

Issues specific to rural practice

Rural health practitioners have the same basic needs for

information as urban primary care clinicians, but rural

practitioners tend to use textbooks more than journals, have

less access to libraries, make less use of online databases, and

ask fewer clinical questions (Dorsch 2000). The greatest

differences exist in acquiring information and the pro-

nounced barriers faced by rural practitioners, including lack

of time, isolation, inadequate library access, lack of equip-

ment, lack of skills, costs; relief cover and inadequate Internet

infrastructure (Dorsch 2000, Kildea et al. 2006).

There is some uncertainty in the literature regarding

shared or multidisciplinary learning. The Standing Commit-

tee on Postgraduate Medical and Dental Education (1999,

p. 11) stated that: ‘a skills training approach in team-

working is neither necessary nor appropriate’. However,

most UK reports call for multi-professional training (Depart-

ment of Health, Welsh Office; Scottish Office Department of

Health; Department of Health and Social Security, Northern

Ireland 1998, SEHD 2002b). Miller et al. (2001) advocated

shared learning strategies to increase the chance of ‘common

learning’. They suggest that case-focused scenarios help to

develop a richer appreciation of the role of others and allow

participants to practise negotiating differences between

roles, facilitating both the development of individual pro-

fessional competence and effective teamwork. Smith and

Alexander (1999, p. 164) warned that inter-professional

education is a more appropriate term than multi-profes-

sional education, as the former implies learning with and

from each other and the latter is simply more than one

profession being educated together. In remote and rural

areas the benefits of inter-professional education are greater

because: (1) there are fewer opportunities for intra-profes-

sional education in remote settings, and (2) there is a greater

need for inter-professional practice in remote and rural

settings (Ibid.). Furthermore, recent policy such as the

Temple Report (SEHD 2002a) recommended establishing

remote and rural strategies for staff development. This

should include time spent in acute units on regular basis in

order to update and maintain clinical skills and network

with colleagues.

Interprofessional training courses

A number of inter-professional courses exist in the maternity

care field. The American Academy of Family Physicians

(AAFP 2003) has offered the Advanced Life Support in

Obstetrics (ALSO) Provider Course (2 day) for all maternity

care providers, and Instructor Course (1 day) (see http://

www.aafp.org/x692.xml?printxml). The two papers evalu-

ating ALSO showed moderate effects of the intervention.

Bower et al. (1997) reported, in a before-and-after study, an

increase in confidence to manage obstetric emergencies in a

self-selected group of 55 family practice residents, but no

effect on residents’ intention to provide maternity services. A

larger before-and-after evaluation of six ALSO courses

(n ¼ 275), found that the increased reported ‘comfort’ and a

‘change in participant practice patterns’ persisted for up to at

least 1 year after participation (Taylor & Kiser 1998). The

J. Ireland et al.


major limitation of this study was that it did not assess the

competence of the participants in the 15 obstetrical emer-

gencies and procedures taught in ALSO.

The Neonatal Resuscitation Programme (NRP) originated

from the USA and the first provider course was offered in

Scotland in September 2002 (Dr M. Munroe, personal

communication), the course having been adapted to local

needs and circumstances (i.e. midwives deliver babies,

different litigation). The main objective, in Scotland, is to

ensure that each delivery room or labour ward is fully

equipped to handle an asphyxiated infant and that every

midwife is trained in neo-natal resuscitation (American

Association of Pediatrics 2006). Achieving this standard is

a challenge for small US community hospitals with limited

staff and few 24-hour in-house physicians (Moore et al.

1989, Bailey & Kattwinkel 1990). This is true for any

rural hospital. A North American alternative proposed by

Moore et al. (1989) used regionally-based, team-oriented

training programmes co-ordinated by a tertiary centre.

Individual training is important but training as a team is

essential.

A pilot programme in Cleveland (USA) – a co-operation

between a tertiary centre and seven community hospitals

(ranging from 500 to 2000 births per annum) – became

known as the ‘Code Pink’ team system (Moore et al. 1989). It

consisted of a non-physician resuscitation scheme, a nearly

identical protocol in all hospitals, ‘mock code’ drills with

dummy equipment to maintain skills, and extensive quality

assurance, both at the local hospital and regional levels. The

heart of the protocol is a flow sheet detailing the performance

of the resuscitation.

Ambulance service staff

A national study in the USA found that paramedics felt very

well prepared from their training in the areas of trauma

assessment (72%) and medical assessment (65%), but were

less likely to feel very well prepared regarding childbirth

(44%) and paediatric-patient management (38%) (Dawson

et al. 2003, p. 118). This difference in confidence can, of

course, depend on the quality of training as well as the

frequency of an event occurring. The Scottish Ambulance

Service trains staff to two basic levels: ambulance technician

and paramedic. The technicians’ course covers pregnancy,

labour complications and dangers, and although it does not

specifically teach resuscitation as part of the maternity

module, the tutors are referred to the Royal College of

Obstetrics & Gynaecology (RCOG) Basic Resuscitation for

newborn resuscitation as essential reading, supported by

videotape evidence (Ambulance Service Association 1999

section 15Æ1, p. 1). No further research literature was found

for ambulance services in remote and rural areas. Given

their crucial role in rural maternity care, this is a noteworthy

gap.

Midwife Ventouse practitioners

Fawdry (1994) suggested that midwives need to accept

whatever responsibility is appropriate to a particular level

of training. The extension to the role of the midwife was

felt to be necessary because, in community-based maternity

units:

(1) Some General Practitioners (GPs) are ‘opting out’ of

intrapartum care. The more recent European Union-dri-

ven guideline on reducing junior doctor hours may fur-

ther impact on maternity care (Tinsley 2001).

(2) Women are not being given a choice in place of delivery

as recommended in Changing Childbirth (Department of

Health 1993).

(3) Loss of continuity, right at the crucial time (second stage

of labour), is undesirable.

(4) In the case of foetal distress under midwifery-led care,

being able to perform a ventouse extraction, skill is

necessary.

The evaluation of this specialist training was very small-

scale consisting of one focus group and 18 questionnaires

(Fawdry 1994). The responding midwives felt that the course

had increased their ability to define foetal position and

station. They reported a high level of confidence when

undertaking their first Ventouse delivery after the course.

They do not expand their role to the detriment of normal

midwifery. Ambulance transfer in the second stage of labour

was prevented for at least 109 women.

Computer/Internet skills and usage

Telemedicine in maternity care is used internationally. Scot-

land makes related recommendations specifically for training:

‘Small units and those in remote and rural areas should

consider using computer technology to enable staff to update

their skills, knowledge and competencies on a regular basis’

(SEHD 2002b). Tele-ultrasound, allows the obstetrician to

diagnose at a distance, both as routine provision and as a

back up in emergency or unexpected or unusual situations

(Nesbitt 1996).

Videoconferencing has been shown by Cronin et al. (2001)

to be useful in testing resuscitation providers in remote

centres. This observational study of the first use of video-

conferencing for this purpose found that it enhances neonatal

resuscitation education in areas where experienced instruc-

tors are in short supply. Tucker et al. (2005) in a question-

naire study of maternity care providers in Scotland with

access to videoconferencing technology reported low actual



use. Nursing (and presumably midwifery) education has

lagged behind despite expressed concerns to provide nurses

with computer literacy (Chambers 1994). More recent work

by Farmer et al. (1999) is consistent with this finding, whilst a

qualitative study in Australia mentioned the same especially

for older apprenticeship-trained nurses, the authors of which

suggest that ‘assisting midwives to access online computers,

and to access and understand recent evidence-based litera-

ture, should facilitate the use of cheaper but effective forms of

learning’ (Fahey & Monaghan 2005, p. 6). Similarly, a

postal-questionnaire study found that e-mentoring is not

commonly practised by New Zealand (NZ) midwives

(Stewart & Wootton 2005, p. S2:92). Whilst a questionnaire

study in the UK reported that video-conferencing for

educational purposes was low amongst GPS (22%) and

nurses (19%) working in rural general practices in the UK

(Richards et al. 2005, p. 4).

A questionnaire survey by Moffat et al. (2001) indicated

high Internet connectivity among Scottish GPs and high levels

of perceived usefulness of the Internet in relation to their

work. Similarly, the above mentioned study by Richards et al.

(2005, p. 6) also reported that rural ‘primary healthcare

practitioners recognize the general benefits of eHealth’. The

latter paper covers computer use, electronic transmission of

data, communication (e.g. tele/videoconferencing) and use of

Internet under the umbrella heading of eHealth. Alternative

forms of service provision described in the literature include

those employed in New Mexico (Shoup 1995), community

health trusts in NZ (Barnett & Barnett 2001) and community

nurse–prescribers in rural Scotland (MacDuff et al. 2001). In

all of these case descriptions, the use of Internet connection

facilitated care provision in remote settings. The literature

suggests that rural outreach specialists and telehealth initia-

tives for both education and clinical services increase the

flexibility for providing care for rural and remote residents

(Humphreys et al. 2002, p. 9).

Education and training summary

Despite the uncertainty in the literature regarding shared or

multidisciplinary learning, overall, multi-professional train-

ing is evaluated as useful by practitioners. However, tradi-

tional hands-on skills’ training is recognized as increasing the

confidence of participants in managing emergency situations.

Midwives need training in, for example, ventouse deliveries

in community-based maternity units since some GPs are

‘opting out’ of intrapartum care. There is potential for the use

of telehealth and Internet-based initiatives for both education

and clinical services. Such interventions can help increase

flexibility in providing education, training and maternity care

in remote and rural settings.

Scotland recognizes that apart from demographic changes,

two other factors will determine the shape of its health care

for the next 15–20 years, namely, the composition and skills

of the healthcare workforce and, secondly, information

and communications technology (Scottish Executive 2005b,

p. 14).

Risk assessment and clinical guidelines

Clinical practice guidelines aim to reduce inappropriate

variations in practice and to promote the delivery of

evidence-based health care. A review by Thomas et al.

(1999) found some evidence that guideline-driven care is

effective in changing the process and outcome of care

provided by professions allied to medicine. To this end, the

Special Health Boards such as NHS Education for Scotland

(NES) and NHS Quality Improvement Scotland (QIS) are

producing policy documents which have some evidence

base and are driving standardization of care through the

use of national core standards and competency frame-

works, e.g. Clinical Standards March 2005, Maternity

Services (QIS 2005); Leadership in Midwifery: A Compe-

tency Framework (NES 2004). These are produced along-

side reports such as EGAMS which give expected

practitioner competencies for the varying levels of care

(SEHD 2002b).

In Wales, another part of the UK with several rural areas

within its boundaries, a multi-professional steering group

developed the All Wales Clinical Pathway for Normal

Labour (http://www.wales.nhs.uk/sites/page.cfm?orgid¼327&

pid¼5785), as a response to increasing levels of unnecessary

intervention in normal labour. However, no evaluation is

available yet (Hunter 2005).

Other countries have also produced regulation to ensure

evidence-based practice. For example, NZ initially focused

on self-declaration, the onus being on the midwife to

demonstrate that she has met the requirements for re-

registration. However, since 2005 NZ midwives must

undertake their midwifery council’s Recertification Pro-

gramme to demonstrate their continuing competence to

practice at the minimum level required for entry to the

profession (New Zealand College of Midwives 2007).

There is a formal audit system similar to that used in the

UK, which includes a random sample of at least 5% of the

personal professional profiles of registered midwives in any

1 year.

Several papers mention risk assessment and early action as

particular skills needed in remote and rural practice. Milne

(2002) describes principles and lessons learned from risk

management developed in high reliability organizations

J. Ireland et al.


(HROs), such as air traffic control and nuclear power plants,

and how they can be applied to perinatal/obstetric units.

‘Managing Obstetrical Risk Efficiently’ (MORE) incorpor-

ating these principles was launched in 2002 by the Society of

Obstetricians and Gynaecologists of Canada (see: http://

www.moreob.com/en/whatWeDo/overview.html). It integ-

rates labour and delivery clinical core content with HRO

principles and reflective learning (Milne 2002). This appears

to be in response to the fact that errors by healthcare

providers are the fourth leading cause of death in the US (all

health care, not exclusively maternity care). No published

evaluation is available to date. One can question whether a

maternity unit can be compared with, for example, an

aeroplane. If there is insufficient crew available, an aeroplane

will not be given clearance to fly. However, an understaffed

maternity unit will still have to provide care.

In summary, accurate risk assessment and early action are

particular skills needed in remote and rural practice and it

appears that evidence-based guidelines are effective in chan-

ging the process and outcome of care provided by maternity

care practitioners.

Discussion

Scotland, in line with many developed (high-income) coun-

tries, is projecting changes in maternity and paediatric

services as a result of the falling birth rate (SEHD 2003,

p. 41). More care is expected to be provided in the

community (Scottish Executive 2005b), and in order to offer

the safest clinical service; some inpatient and other specialist

clinical care will be concentrated in fewer centres. This

change will require continued investment in training and

professional development of the health service workforce

(SEHD 2003, Scottish Executive 2005b). However, a large

proportion of the required training will be generic, i.e. not

specific to rural practitioners, for example good communica-

tion skills, which are recognized as a key attribute of a ‘good

midwife’ (Nicholls & Webb 2006). Both the UK and NZ rely

on evidence produced by practitioners in the format of

portfolios, but there is little evidence of the actual effective-

ness of portfolios (McMullen et al. 2003).

The medical workforce in Scotland is under pressure

(SEHD 2002a), since (1) the European Union Working Time

Directive was applied; (2) more female doctors are being

trained than 40 years ago who both less likely to work full

time and more likely to stop working (have career breaks)

than their male counterparts; (4) many doctors originally

from the Indian-subcontinent are reaching retirement age;

and (5) younger doctors find long working hours less

acceptable than did their predecessors (Elliot et al. 2002,

SEHD 2002a). The UK tends to rely on the immigration of

health professionals as a short-term fix for shortages (Bloor

& Maynard 2003). The shortage of healthcare professionals

willing and able to work in rural areas is a worldwide

problem, for example in Canada (Buske 2001), Australia

(Strasser et al. 2000, Joyce et al. 2006), as well as in a range

of countries where GPs undertake (some) rural maternity care

(Wiegers 2003).

Implications for practice and policy

Providing services over large and sparsely populated geo-

graphical areas has always been a challenge in Scotland.

At the moment there are proposals to centralize many

services, such as emergency departments and maternity care,

by removing these from smaller hospitals (Christie 2005,

p. 924). Clearly, the drive towards fewer centres for

specialist care will affect maternity services in remote and

rural areas. One direct consequence is the increasing reliance

on midwives (and other healthcare practitioners such as

ambulance staff) to assess risk accurately and undertake

early action in remote and rural maternity practice. The

increased reliance on midwives means that their CPD needs

to be of the highest quality. Commonly used CPD courses

such as ALSO, NRP and MORE are not yet evaluated.

There is an urgent need for appropriately conducted before-

and-after studies (control groups) to improve our evidence

base.

Thomas et al. (1999) suggested that evidence-based

guidelines are effective in changing the process and outcome

What is already known about this topic

• There exists a confusing variety of definitions of the

terms ‘remote’ and ‘rural’.

• A variety of explanations of the meaning and assess-

ment of ‘skills and competence’ exist.

• A few good quality studies exist on skills, competencies

and continuous professional development needed for

remote and rural maternity care.

What this paper adds

• Provides a review of the literature relating to the key

issues of competence, training, recruitment and retent-

ion in remote and rural maternity care.

• Based on this review, and on the study which followed

on from it (Kiger et al. 2003, Tucker et al. 2005)

directions for future research are outlined.



of care provided by maternity care practitioners. A Scottish

report recommended extending the effective use of managed

clinical networks and establishing remote and rural strat-

egies for staff development (SEHD 2002a). This should

include strategies for time to be spent by rural practitioners

in acute units on regular basis. However, various practical

considerations for rural staff, such as travel time from rural

areas to central units, difficulty in providing cover for absent

staff, or childcare and family issues for staff being away

overnight, need to be addressed to make such strategies

workable.

Conclusion

We found very little high-quality literature specifically focus-

ing on (training of) skills and competencies related to rural

maternity care. Very little research literature was found for

ambulance services in remote and rural areas, which is

important as they have an increasingly crucial role to play in

rural maternity care. The descriptive nature of much of the

published literature, although covering a wide range of

developed countries, is indicative of the scarcity of rigorous

investigations of skills and competence. We found a body of

literature on related and important aspects of rural health

care, which was neither focused on maternity care, nor unique

to it. For example, there is literature on ‘competency’, staffing

problems and related difficulties on recruitment and retention,

distance to central specialist healthcare units, skills training,

and skills maintenance and so on. It is widely recognized that

rural practitioners face greater difficulties than their urban

counterpart in maintaining competencies and updating their

skills. Some of the literature suggested that there is potential

for the use of telehealth and Internet-based initiatives for both

education and clinical services in rural areas.

Those involved in designing training courses and providing

CPD to rural practitioners should be reminded of the

particular barriers facing rural practitioners, e.g. geograph-

ical isolation, inadequate library access, lack of equipment,

higher costs of travel and inadequate relief cover. There is

potential for increasing distant learning facilitated by video-

conferencing or Internet access in remote and rural areas.

However, skills in using communication technology and

computer literacy of maternity staff will have to be addressed,

for example that of the experienced midwives who have been

trained prior to the 1990s.

A further recommendation is that those in charge of

evaluating the midwife’s competency should consider other

ways than the currently popular portfolios to validate

midwives’ ability of gain or retain specific competencies, as

portfolios do not appear to be evidence-based.

The final obvious conclusion is that more research is

needed on the levels of skills and competencies required for

maternity care professionals, practising in remote and rural

areas. In particular evaluation research in the widely used

training courses such as ALSO, MORE and NRP is needed to

expand our evidence base in this field. However, we are very

well aware that the reasons why such research has not yet

been conducted are inherent to this area, i.e. relative small

populations in widely-dispersed areas (making research

expensive or impossible); competition for resources (of all

kinds) between rural and urban areas; and remote and rural

areas often occupying the political periphery.

Acknowledgements

We would like to thank Moira Napper, Amudha Poobalan and

Lakshmi Mandava (all at the University of Aberdeen) for their

help with the literature search. Further thanks are due to the

NHS Education Steering Group and our Professional Advisory

Group. NHS Education for Scotland (grant number CP123)

funded the research upon which this review is based. We are

also grateful for the comments and suggestions made by the

anonymous reviewers and editor on our earlier submission.

Author contributions

EVT was responsible for the study conception and design and

JI, HB, EVT and VH were responsible for the drafting of the

manuscript. JI, HB, EVT, VH, JF, FH, JT, AK and JC

performed the data collection and JI, HB and EVT performed

the data analysis. HB, EVT, VH, JF, JT and AK obtained

funding and JI, HB, EVT and VH provided administrative

support. JI, HB, EVT, VH, JF, FH, JT, AK and JC made

critical revisions to the paper. EVT, JT and AK supervised the

study. JI and EVT performed other tasks.

References

American Academy of Family Physicians (AAFP) (2003). Retrieved

from http://www.aafp.org/x692.xml?printxml, on October 2003.

Ambulance Service Association (1999) Basic Training Manual.

IHCD, London.

American Association of Pediatrics (2006) Retrieved from http://

www.aap.org/nrp/nrpmain.html, on October 2006.

Anderson T. (1999) Are we training competent midwives? Practising

Midwife 2, 4–5.

Bailey C. & Kattwinkel J. (1990) Establishing a neonatal resuscita-

tion team in community hospitals. Journal of Perinatology 10,

294–300.

Baird A.G., Jewell D. & Walker J.J. (1996) Management of Labour

in an isolated rural maternity hospital. British Medical Journal

312, 223–226.

J. Ireland et al.


Barnett P. & Barnett J.R. (2001) Community ventures in rural health:

the establishment of community health trusts in southern New

Zealand. Australian Journal of Rural Health 9, 229–235.

Bloor K. & Maynard A. (2003) Planning Human Resources in

Health Care: Towards an Economic Approach. An International

Comparative Review. Canadian Health Services Research Foun-

dation, Ontario.

Bower D.J., Wolkmir M.S. & Schubot D.B. (1997) The effects of the

ALSO course as an educational intervention for residents. Family

Medicine 28, 187–193.

Bryers H.M.M., Amor S., Groves J. & Devlin B. (2001) A Review of

Maternity Services for Highland Health Board. Highland Health

Board, Inverness.

Buske L. (2001) A crisis aborning in maternity and newborn care?

Canadian Medical Association Journal 164, 681.

Caudle M.R., Clapp M., Stockton D. & Neutens J. (1995) Advanced

obstetrical training for family physicians: the future for rural

obstetric care. Journal of Family Practice 41, 123–125.

Christie B. (2005) Building a Healthier Scotland. British Medical

Journal 330, 924.

Chambers M. (1994) Information technology and the curriculum.

(Wainwright P., ed.). Nursing Informatics. Churchill Livingston,

Edinburgh, UK, pp. 139–158.

Cronin C., Cheang S., Hlynka D., Adair E. & Roberts S. (2001)

Videoconferencing can be used to assess neonatal resuscitation

skills. Medical Education 35, 1013–1023.

Dawson D.E., Brown W.E. & Harwell T.S. (2003) Assessment of

nationally registered emergency medical technician certification

training in the United States: the LEADS Project. Pre-Hospital

Emergency Care 7, 114–119.

Department of Health (1993) Changing Childbirth: Part 1. Report

of the Expert Group on Acute Maternity Services. HMSO,

London.

Department of Health, Welsh Office; Scottish Office Department of

Health; Department of Health and Social Security, Northern Ire-

land (1998) Why mothers die – Report on the Confidential

Enquiries into Maternal Deaths in the UK 1994–1996. HMSO,

London.

Dorsch J.L. (2000) Information needs of rural health professionals: a

review of the literature. Bulletin of the Medical Librarians

Association 88, 346–354.

Duffield C. (1991) Maintaining competence for the first-line nurse-

managers: an evaluation of the use of the literature. Journal of

Advanced Nursing 16, 55–62.

Elliot R., Marromaras K., Scott A., Bell D.N.F., Antonazzo E.,

Gerova V., Van der P.M. (2002) NHS Labour Markets in Scotland.

Final Report to Scottish Executive Health Department. HERU,

University of Aberdeen, UK.

Fahey C.M. & Monaghan J.S. (2005) Australian rural midwives:

perspection on continuing professional development. Rural and

Remote Health 5, 468: 1–6, retrieved from http://rrh.dea-

kin.edu.au, on September 2006.

Farmer J., Richardson A. & Lawton S. (1999) Improving access to

Information for nursing staff in remote areas: the potential of the

Internet and other networked information services. International

Journal of Information Management 19, 49–62.

Farmer J., Iversen L. & Baird G. (2001) Rural deprivation: reflecting

reality. British Journal of General Practice 51, 486–491.

Farmer J., Lauder W., Richards H. & Sharkey S. (2003) Dr John has

gone: assessing health professionals’ contribution to remote rural

community sustainability. Social Science and Medicine 57(4), 673–

686.

Fawdry R. (1994) Midwives and the care of ‘normal’ childbirth.

British Journal of Midwifery 2, 302–303.

Fullerton J.T. & Thompson J.B. (2005) Examining the evidence for

The International Confederation of Midwives’ essential compe-

tencies for midwifery practice. Midwifery 21, 2–13.

Girot E.A. (1993) Assessment of competence in clinical practice: a

review of the literature. Nurse Education Today 13, 83–90.

GMC (2003) Tomorrow’s Doctors: Recommendations on Under-

graduate Medical Education. GMC, London. Retrieved from

http://www.gmc-uk.org/education/undergraduate/tomorrows_doc-

tors.asp.

Hays R.B., Craig M.L., Wise A.L., Nicols A., Mahoney M.D. &

Adkins P.B. (1994) A sampling framework for rural and remote

doctors. Australian Journal of Public Health 18, 273–276.

Hoggart K. (1990) Let’s do away with rural. Journal of Rural Studies

6, 245–257.

Hogston R. (1993) From competent novice to competent expert: a

discussion of competence in light of the Post Registration Edu-

cation and Practice Project. Nurse Education Today 13, 167–

171.

Humphreys J., Hegney D., Lipscombe J., Gregory G. & Chater B.

(2002) Whither rural health? Reviewing a decade of progress in

rural health. Australian Journal of Rural Health 10, 2–14.

Hunter B. (2005) Exploring the implementation of the All-Wales

clinical pathway for normal labour. Midwifery Matters 106, 4.

ICM (2002) Competencies ICM (International Confederation of Mid-

wives). Retrieved from http://www.internationalmidwives.org/

modules.php?op¼modloadNews&file¼article&sid¼27, on April

2006.

International Council of Nurses (2001) International Competencies

for the Generalist Nurse. ICN, Geneva.

Joyce C.M., McNeill J.J. & Stoelwinder J.U. (2006) More doctors,

but not enough: Australian medical workforce supply 2001–2012.

Medical Journal of Australia 184(9), 441–446.

Kiger A., Tucker J., Bryers H., Caldow J., Farmer J., Harris F.,

Hundley V., Ireland J. & van Teijlingen E. (2003) Sustainable

Maternity Service Provision in Remote and Rural Areas of Scot-

land: The Scoping of Core Multidisciplinary Skills and Exploration

of Best Practice in the Development and Maintenance of Skills

(Final Report NHS Education for Scotland). University of Aber-

deen, Aberdeen.

Kildea S., Barclay L. & Brodie P. (2006) Maternity care in the bush:

using the Internet to provide educational resources to isolated

practitioners. Rural and Remote Health 6: 559: 1–12. Retrieved

from http://rrh.deakin.edu.au, on September 2006.

MacDuff C., West B. & Harvey S. (2001) Telemedicine in rural care

part 2: assessing the wider issues. Nursing Standard 15, 33–37.

Manley K. & Garbett B. (2000) Paying Peter and Paul: reconciling

concepts of expertise with competency for a clinical career struc-

ture. Journal of Clinical Nursing 9, 347–359.

McMullen M., Endacott R., Gray M.A., Jasper M., Miller C.M.I.,

Sholes J. & Webb C. (2003) Portfolios and assessment of compe-

tence: a review of the literature. Journal of Advanced Nursing 41,

283–294.



Miller C., Freeman M. & Ross N. (2001) Interprofessional Practice

in Health and Social Care. Arnold, London.

Milne J.K. (2002) Managing risk, clinical error, and quality of care.

Journal of Obstetrics and Gynecology of Canada 24, 717–720.

Moffat M.O., Moffat K. & Cano V. (2001) GPs and the Internet: a

questionnaire survey of Internet connectivity and use in Lothian.

Health Bulletin 59, 120–125.

Moore J., Andrews L., Henderson C., Zuspan K.J. & Hertz R.H.

(1989) Neonatal resuscitation in community hospitals. A regional

based team-orientated training program co-ordinated by a tertiary

center. American Journal of Obstetrics and Gynecology 161, 849–

855.

NES (2004) Leadership in Midwifery: A Competency Framework.

NHS Education Scotland, Edinburgh.

Nesbitt T.S. (1996) Rural Maternity Care: New Models of Access.

Birth 23, 161–165.

New Zealand College of Midwives (2007) Midwifery Standards

Review. Retrieved from http://www.midwife.org.nz/index.cfm/

standardsreveiw, on August 2006.

Nicholls L. & Webb C. (2006) What makes a good midwife? An

integrative review of methodologically-diverse research. Journal of

Advanced Nursing 56, 414–429.

NMC News (2003a) Advice on developing practice and accepting

gifts. NMC News April, 13.

NMC News (2003b) Fitness to practice consultation ahead. NMC

News April, 6.

Nuttall N., Steed M. & Donachie M. (2002) Referral for secondary

restorative dental care in rural and urban areas of Scotland: find-

ings from the Highlands & Islands Teledentistry Project. British

Dental Journal 192, 224–228.

QIS (2005) Clinical Standards March 2005, Maternity Services. NHS

Quality Improvement Scotland, Edinburgh. Retrieved from http://

www.nhshealthquality.org/nhsqis/files/maternity%20Services%20

(Mar%202005)%20revised%20April%2005.pdf, on February

2006.

Richards H., King G., Reid M., Servaraj S., McNicol I., Brebner E. &

Godden D. (2005) Remote working: survey of attitudes to eHealth

of doctors and nurses in rural general practices in the United

Kingdom. Family Practice 22, 2–7.

Ricketts T., Johnson-Webb K. & Taylor P. (1998) Definitions of

Rural: A Handbook for Health Policy Makers and Researchers.

Equals Three Communications, Office of Rural Health Policy,

Bethesda, MD. Retrieved from http://www.shepscenter.unc.

edu/research_programs/rural_program/ruralit.pdf on September

2006.

Rolfe I.E., Pearson S.A., O’Connell D.L. & Dickinson J.A. (1995)

Finding solutions to the rural doctor shortage: the roles of selection

versus undergraduate medical education at Newcastle. Australian

and New Zealand Journal of Medicine 25, 512–517.

Rousseau N. (1995) What is rurality? In Rural General Practice in

the United Kingdom. Occasional paper 71 (Cox J., ed.), Royal

College of General Practitioners, London.

Scottish Executive (2003) Rural Scotland: Taking Stock. Scottish

Executive, Edinburgh. Retrieved from http://www.scotland.

gov.uk/Publications/2003/03/16701/19559 on October 2006.

Scottish Executive (2005a) Rural Definitions Map. Scottish Execu-

tive, Edinburgh. Retrieved from http://www.scotland.gov.uk/

Topics/Rural/rural-policy/16780/6661 on September 2006.

Scottish Executive (2005b) Building a Health Service Fit for the

Future. Scottish Executive, Edinburgh. Retrieved from http://

www.scotland.gov.uk/Publications/2005/05/23141307/13348 on

September 2006.

Scottish Executive Health Department (SEHD) (2001) A Frame-

work for maternity services in Scotland. SEHD, Edinburgh.

Retrieved from http://www.scotland.gov.uk/library3/health/ffms-

00.asp.

Scottish Executive Health Department (SEHD) (2002a) Future

Practice: Proposals of an Advisory Group Commissioned by the

SEHD to Review the Scottish Medical Workforce (Temple

Report). SEHD, Edinburgh. Retrieved from http://www.

scotland.gov.uk/library5/health/fpmr-00.asp.

Scottish Executive Health Department (SEHD) (2002b) Implement-

ing A Framework for Maternity Services in Scotland – Report of

the Expert Group on Acute Maternity Services (EGAMS). SEHD,

Edinburgh. Retrieved from http://www.scotland.gov.uk/library5/

health/egas.pdf.

Scottish Executive Health Department (SEHD) (2003) Partnership

For Care: Scotland’s Health White Paper. SEHD, Edinburgh.

Retrieved from http://www.scotland.gov.uk/library/health/pfc.

Scottish Office (1996) Scottish Rural Life – An Update. A Revised

Socio-Economic Profile of Rural Scotland. Scottish Office, Edin-

burgh.

Shoup S. (1995) Red River Project: Expanded Scope Program for

New Mexico Medics. Journal of Emergency Medical Services 20,

44–47.

Smith L. & Alexander J. (1999) Educating the carers. In Community-

Based Maternity Care (Marsh G. & Renfrew M., eds), Oxford

University Press, Oxford, pp. 153–172.

Standing Committee on Postgraduate Medical and Dental Education

(1999) Equity and Interchange: Multiprofessional Learning and

Working. The Stationery Office, London.

Stewart S. & Wootton R. (2005) A survey of e-mentoring among

New Zealand midwives. Journal of Telemedicine and Telecare 11

(Suppl. 2), 90–92.

Storey L., Howard J. & Gillies A. (2002) Competency in Healthcare:

A Practical Guide to Competency Frameworks. Radcliffe Medical

Press, Abingdon.

Strasser R.P., Hays R.B., Kamien M. & Carson D. (2000), Is

Australian rural practice changing? Findings from the national

rural GP study. Australian Journal of Rural Health 8, 222–

226.

Taylor H. & Kiser W.R. (1998) Reported comfort with obstetrical

emergencies before and after participation in the Advanced Life

Support in Obstetrics course. Educational Research and Methods

30, 103–107.

Thomas L., Cullum N., McColl E., Rousseau N., Soutter J. &

Steen N. (2003) Guidelines in professions allied to medicine.

Cochrane Database of Systematic Reviews, Issue I Art no.

CD000349.

Tinsley V. (2001) Rethinking the role of the midwife. Midwife

Ventouse practitioners in community maternity units. MIDIRS

11(3), Suppl. 2, S6–S9.

Tucker J., Kiger A., Hundley V., Harris F., Caldow J., Farmer J.,

Bryers H., Ireland J. & van Teijlingen E. (2005) Sustainable

maternity services in remote and rural Scotland? Quality and

Safety in Health Care 14, 34–40.

J. Ireland et al.


Wang L. (2002) A comparison of metropolitan and rural medical

schools in China: Which schools provide rural physicians? Aus-

tralian Journal of Rural Health 10, 94–98.

Weinert C., Boik R.J. (1995) MSU rurality index: development and

evaluation. Research Nursing & Health 18, 453–463.

Wiegers T.A. (2003) General practitioners and their role in maternity

care. Health Policy 66, 51–59.

Williams N., Shucksmith M., Edmond H. & Gemmell A. (1998)

Scottish Rural Life Update: A Revised Socio-Economic Profile of

Rural Scotland. Scottish Office Central Research Unit/TSO, Edin-

burgh.

Woodruffe C. (1993) What is meant by a competency? Leadership

and Organisation Development Journal 14, 29–36.

World Health Organization (2001) Nurses and Midwives for Health:

WHO European Strategy for Nursing and Midwifery Education.

Guidelines Section 2: Competency-based Education and Training.

WHO, Copenhagen.



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

Documents

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