Date of Award

2026

Keywords

Paramedicine, paramedic, emergency medical technician, emergency medical service, volunteer ambulance officers, volunteers, allied health personnel, born before arrival, out-of-hospital birth, unplanned out-of-hospital birth, obstetrics, pregnancy complications, virtual reality, simulation, serious games, parturition

Document Type

Thesis

Publisher

Edith Cowan University

Degree Name

Doctor of Philosophy

School

Western Australian Academy of Performing Arts

First Supervisor

Luke Hopper

Second Supervisor

Brennen Mills

Third Supervisor

Sara Hansen

Fourth Supervisor

Belinda Flanagan

Abstract

Out-of-hospital births (OOHBs) are births which occur outside a hospital setting. This includes planned home births attended by midwives, or unplanned OOHBs where the intention was to birth in a hospital or maternity centre, however, occurs in an unintended location. Prehospital clinicians, inclusive of registered paramedics and volunteer ambulance officers (VAOs) infrequently attend OOHBs, as most births occur in maternity wards as anticipated. OOHBs comprises < 1% of emergency ambulance requests and requires specialised skills for prehospital clinicians to competently manage birthing and potential complications. As exposure to birthing is so rare, these specialised skills and knowledge are underutilised and subject to rapid decay. Compounding the problem, obstetrics is infrequently taught across undergraduate education, in-service training, or within individual clinician’s continuing professional development. Placements shadowing midwives are scarce due to nursing and medical students receiving priority. Previous research regarding OOHBs is limited, nonetheless suggests prehospital clinicians are underprepared to manage an OOHB, which has serious patient safety implications. The present research sought to explore prehospital clinicians’ preparedness and confidence in managing OOHBs. It also investigates whether a digital training solution such as virtual reality (VR) simulation may reduce the theory-practice gap and assist in competency retention.

Publication one provides a comprehensive methodology outline which is applied to Study One; a scoping review of prehospital clinician and birth parent experiences with OOHBs. Risk factors, complications and interventions provided by prehospital clinicians, as well as barriers and challenges to providing appropriate OOHB care are reviewed. This research explores the experiences and perspectives of prehospital clinicians and birth parents, identifying potential deficits in confidence and competency for prehospital clinicians internationally. Studies Two and Three involve qualitative investigations of Australian prehospital clinician confidence in attending an OOHB, obstetrics education and training, and actual experiences with OOHBs. Study Two canvases paramedics, while Study Three delves into rural VAO perspectives. Findings from both studies suggest prehospital clinicians largely lack confidence with OOHBs, are concerned about skills decay given infrequent exposure and training, and would prefer more regular obstetrics training and education. Both cohorts had attended uncomplicated and complicated births, including some with adverse outcomes. Study Four explores Australian and New Zealand confidence, education and training, and experiences with OOHB via a mixed-methods online questionnaire, providing corroborating yet more generalisable findings than the preceding two investigations. Study Four found prehospital clinicians previously exposed to an OOHB were more confident attending a birth than clinicians without exposure, however, overall confidence was generally low and more frequent and accessible training is desired by prehospital clinicians. Going some way to explore enhancing accessibility of training, Study Five discusses the design and development of a novel VR simulation program ‘NEONATE-in-VR’ to assess and manage a neonate born out-of-hospital. A pilot study testing the NEONATE-in-VR program found knowledge and confidence was significantly improved post-intervention, and was a viable option to provide experiential exposure to birthing.

OOHBs are a low-frequency high-risk event. This thesis provides additional data indicating prehospital clinicians’ lack confidence and exposure to these cases; often having no exposure prior to managing an emergency birth. VR simulation can assist with experiential exposure and help maintain proficiency in OOHB skills and knowledge. This has important implications for educators and emergency ambulance organisations wishing to improve patient safety and outcomes, as well as to researchers seeking to develop other healthcare digital simulation programs.

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Link to publisher version (DOI)

10.25958/bzxf-6t28