Many midwives continue to use Continuous Electronic Foetal Monitoring (CEFM) on low risk women in labour, despite overwhelming clinical evidence that it is unnecessary. The use of CEFM on low risk labouring women has been linked to rising rates of medical intervention during labour and birth with no improvement in long term neonatal outcomes. This study examined the decision-making processes of midwives who used CEFM on low risk labouring women. Whilst a number of previous studies have examined various aspects of CEFM, none specific to midwives’ decision-making and CEFM on low risk labouring women. This study contributes to the literature in this specific area. The theoretical origins of Symbolic Interactionism and Grounded Theory (GT) methods underpin this study. SI, a sociological theory that emphasises meaning in human interactions and behaviours is used in this study to focus on the behaviours and interactions of five midwives’when deciding to use CEFM on low risk labouring women. Primary data were collected by conducting unstructured interviews and systematic analysis was undertaken using GT methods to generate a substantive theory of: Midwives’ CEFM decision-making despite evidence based guidelines. The midwives made the decision that led to CEFM at two key points in the woman’s labour care. Firstly, during the initial assessment of the woman and foetus, some midwives decided to use a baseline CTG rather than intermittent auscultation (IA). Secondly, following initial assessment, the midwives made an individualised assessment and decided whether to use CEFM as the method to monitor the foetus during labour. Trust was identified as the core variable, having a profound effect on the midwives’ decision-making at these two points. Another significant factor that impacted on decision-making was staff workload. Recommendations relating to these findings promote that labouring women be central and intimately involved in decisions about foetal monitoring. Workplace reforms, such as the introduction of midwifery led models of care for women within a community setting are recommended to address professional trust and workload issues. Through the implementation of these recommendations it is expected that midwives will embrace the notion of woman centred care and that the unnecessary use of CEFM on low risk labouring women will be reduced.

How to allocate resources in the health care sector is academically dealt with within the subject of health economics. Economic evaluations are within this area used to compare the costs and effects of medical interventions with the purpose to help decision makers decide how to allocate resources. Oxygen deficiency in the foetus during birth can lead to severe life long injuries in the child. In high-risk deliveries, it is therefore considered necessary to use foetal surveillance with a scalp electrode and the choice is between surveillance with internal cardiotocography (CTG) and surveillance with ST analysis. The standard procedure is in most hospitals currently CTG, which records the foetal heart rate and the uterine contractions. The second strategy, in this thesis referred to as ST analysis, complements CTG with foetal electrocardiography(ECG) and ST analysis. The objective of this report is to from a societal perspective determine the cost-effectiveness of using ST analysis in complicated deliveries, compared to the use of CTG alone. A cost-utility analysis was performed based on a probabilistic decision model incorporating the relevant strategies and outcomes. The costs and effects of the two different treatment strategies were compared in a decision tree. Discounted costs and quality-adjusted life-years (QALYs) were measured and simulated over a life-time perspective. The analysis resulted in an incremental effect of 0.005 QALYs for the ST analysis strategy, when compared to the CTG strategy. ST analysis was also associated with a €30 lower cost. Thus, CTG is dominated by the ST analysis strategy. The probability that ST analysis is the cost-effective alternative is high for all values of willingness-to-pay for a QALY, which means that a decision to implement the ST analysis strategy based on the results of this thesis would be surrounded by a low degree of uncertainty.

<p>How to allocate resources in the health care sector is academically dealt with within the subject of health economics. Economic evaluations are within this area used to compare the costs and effects of medical interventions with the purpose to help decision makers decide how to allocate resources.</p><p>Oxygen deficiency in the foetus during birth can lead to severe life long injuries in the child. In high-risk deliveries, it is therefore considered necessary to use foetal surveillance with a scalp electrode and the choice is between surveillance with internal cardiotocography (CTG) and surveillance with ST analysis. The standard procedure is in most hospitals currently CTG, which records the foetal heart rate and the uterine contractions. The second strategy, in this thesis referred to as ST analysis, complements CTG with foetal electrocardiography(ECG) and ST analysis.</p><p>The objective of this report is to from a societal perspective determine the cost-effectiveness of using ST analysis in complicated deliveries, compared to the use of CTG alone. A cost-utility analysis was performed based on a probabilistic decision model incorporating the relevant strategies and outcomes. The costs and effects of the two different treatment strategies were compared in a decision tree. Discounted costs and quality-adjusted life-years (QALYs) were measured and simulated over a life-time perspective.</p><p>The analysis resulted in an incremental effect of 0.005 QALYs for the ST analysis strategy, when compared to the CTG strategy. ST analysis was also associated with a €30 lower cost. Thus, CTG is dominated by the ST analysis strategy. The probability that ST analysis is the cost-effective alternative is high for all values of willingness-to-pay for a QALY, which means that a decision to implement the ST analysis strategy based on the results of this thesis would be surrounded by a low degree of uncertainty.</p>

Thesis (M.D.)-University of Natal, Durban, 1979.