midwives tended to give higher ratings than did the consultant paediatricians, indicating a significant bias in clinical judgement between the professional groups. Despite this bias, it was clear that both consultant paediatricians and senior midwives rated the quality of midwife
examinations more highly. Even where differences in the quality of examinations were not statistically significant, the trend was still in favour of
midwives for most aspects of the examination.
These ratings of the video analysis accord with the results of parents’ satisfaction with the newborn examination48presented in the previous chapter. Mothers reported higher satisfaction when a midwife rather than an SHO carried out the examination, and reported that midwives discussed physical and behavioural healthcare issues more often, again in accordance with the video-recorded observations. The direct observation and the mothers’ views provide consistent results. The results also accord with a recent comparison of trainee paediatricians with advanced neonatal nurse practitioners (ANNPs) concerning the detection rate for abnormalities, which found the latter to be more effective.12The findings of higher quality of examinations by midwives and more effective examinations by ANNPs may be due to the more intensive and formal training that they receive compared with that received by SHOs.
For certain components of the examination, neither midwives nor SHOs were rated highly. In particular, the screening for hip problems, particularly using Barlow’s test, was often poor, family history of problems was rarely discussed and the baby was often not relaxed during the hip examination or during the auscultation of the
heart. In many instances, Barlow’s test was rated as not performed and the items had to be excluded from the analysis. Previous studies have also highlighted poor examiner skills in relation to screening for developmental dysplasia of the hip.47
Analysis of videotapes allows objective assessments of the same behaviours by different observers, but it has limitations. It is possible that despite the removal from the tapes of all visual and verbal reference to the examiner’s identity, the raters may have partly ‘guessed’ the examiner’s profession on the assumption that most midwives are female. However, many of the SHOs were also female, and as the midwives were rated higher, we conclude that no bias was evident. The observer of the videotaped examinations is not necessarily able to see what the examiner sees, for example when screening for cataracts, or to hear what the examiner hears, for example when screening for heart disease. Therefore, for some aspects of quality control, additional methods of assessment, such as audio playing of different heart recordings to assess the correct detection rates of heart murmurs, are required.
Conclusions on quality
assessment
This part of the study suggests, in accordance with Hall,1,3that with adequate training and support the examinations may be carried out by midwives. In fact, the quality of midwife examinations may not only be as good as but exceed the quality of current examinations by SHOs. The findings strongly suggest that SHOs would benefit from a formalised introduction and training for the newborn examination similar to that provided for midwives. Furthermore, greater emphasis in training could be placed on communication skills and health education. There is scope in the current training to enhance the quality of newborn assessments concerning, for example, screening for developmental dysplasia of the hip and family history taking. The use of video recordings for purposes of training and supervision47,49and to ensure objectivity of assessors could become an integral part of training and is likely to improve the performance of examiners of the newborn.
Summary
Appropriate referrals are an important output of the newborn examination. No significant
difference was detected between SHOs and midwives in appropriate referrals to hospital for major or minor problems (4.6% for SHOs vs 5.9% for midwives, OR = 1.2, p = 0.54) or for
appropriate community referrals (3.1% for SHOs vs 4.2% for midwives, OR = 1.25, p = 0.55). Neither was there a significant difference in inappropriate referrals to hospital (1.0% SHOs vs 1.2% midwives, OR = 1.2, p = 0.8). The only significant difference was for inappropriate
community referrals to midwives or GPs (0% SHOs vs 2.5% midwives), which were informal and would be part of routine visits. Few new problems were identified at the 10-day examination. Problems identified during the first year of life were assessed as ‘identifiable’ or not ‘identifiable’ at the routine examination of the newborn, as an attempt to check false-negative referral rates. There was close similarity between SHOs and midwives on rates of problems presenting in the first year, which were identifiable and were actually identified at the newborn examination. There is therefore no evidence of a significant difference in appropriate referral between the two professional groups, although there was some indication of more heart murmurs detected at 3 months but not identified by SHO examinations.
Introduction
One of the major purposes of the routine
examination is to screen for health problems and this may result in a referral for a minor or potentially major problem. Owing to the relative rarity of major conditions, including of the heart or hips, and the problems with early progression, the trial is not set to test differences in rates of identification for individual conditions between the randomised arms. Rather, differences in accuracy of testing were assessed by quality control using videos, as reported in the previous chapter, and here we consider overall
appropriate referral rates. The research
hypothesis is that there is no significant difference between SHO and midwife examiners in the rate
of appropriate referral from the routine newborn examination.
In view of the examination being only a weak screening procedure, with many problems not manifesting until later or resolving spontaneously, it is clear that it would not be possible to test for false- or true-positive or -negative referral rates. We nevertheless used various methods to make useful comparisons between the randomised groups. It was decided and agreed with the HTA funders that in order to assess and compare safety between examination by midwife or SHOs, the study would focus on appropriateness of referrals rather than on the outcome of referrals. The aim of this part of the study was to identify and
compare rates of appropriate referral as judged by independent consultant paediatricians and rates of problems missed. Data were also collected by questionnaire from GPs and mothers to identify further problems and use of health services. Results of referrals were checked by hospital note search and from GPs.
An appropriate referral was defined as one where there was indication that the child might be at risk or require further diagnosis, intervention,
monitoring, or reassurance required to the parents, and which if missed could be detrimental to the child’s health. Appropriate referrals have been further classified as potentially major or minor according to the judgement of the independent consultant paediatricians.
As a measure of safety, the study assessed appropriate referral:
● within 24 hours of delivery at the neonatal
discharge examination (routine examination of the newborn)
● 10–14 days after birth for 50% of the sample
who received a second detailed neonatal examination.
To assess the rate of problems missed, data were also collected for problems identified during the first
● 3 months, which included problems identified
at the 6–8-week check 25
Chapter 5
● 12 months, which included problems identified
at the 6–9-month check.
Expert independent consultant paediatric opinion was taken to ascertain if any of the problems identified at these times could or should have been detected in the 24-hour check and so would be potentially ‘missed’ problems.
At the 24-hour examination, a number of referral options were available to the examiner (Figure 3).