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Obstetrics and birth: effects of experiences and gender bias on student test scores

02 March 2021
Volume 11 · Issue 1



Paramedic education requires all students have the experience of attending childbirth. Obstetric (OB) experiences are limited for students in hospitals and even more so in the field. Gender bias may exist in hospital OB rotations for paramedic students but research on this is limited. This study is intended to examine whether a sex bias exists in field or hospital placements and if that bias correlates to OB test scores.


Using data from Fisdap, numbers of OB experiences were analysed and compared to individual student sex and experience type (hospital clinical, field or skills laboratory). The number of experiences were compared to that student's score on the OB section of the Fisdap paramedic readiness examinations version 3 (PRE3) or version 4 (PRE4).


Of 12 090 paramedic students, male (n=5625) and female (n=2682) students who took the PRE3 had equal average scores of 0.76 and male (n=2498) and female (n=1285) students who took the PRE4 had average scores of 0.77 and 0.79 respectively. Students who took the PRE3 saw a mean of 4.32 births, a majority of which were in hospital (3.68); there was minimal difference in experiences between male and female students in field or skills laboratory settings, but women saw more births in hospital settings (3.92) than men (3.43). Students who took the PRE4 saw a mean of 4.54 births, a majority of which were in hospital (3.8) and there was minimal difference in experiences between male and female students in field or laboratory settings but women students saw more births in hospital (4.06) than men (3.54).


There is no correlation between the number of OB emergency encounters by paramedic students and their OB test scores. However, a potential gender bias exists as female students tend to have more labour and birth experiences in hospital settings than their male counterparts, while number of experiences in lab and field settings were similar.

Prehospital childbirth emergencies and deliveries are rare (Verdile et al, 1995) but can involve complications for both the mother and the newborn, leading to increased morbidity and mortality (McLelland et al, 2014; Flanagan et al, 2017).

To complete paramedic education each student has to participate in childbirth experiences through three supervised modes of formal instruction—clinical experience in hospital and prehospital settings, and simulation in the clinical skills laboratory. The total number of newborn deliveries that paramedic students must participate in, in any of these settings, is established through recommendations made by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP).

It is mandatory for students to complete an accredited programme in obstetrics (OB) and childbirth before sitting the National Registry of Emergency Medical Technicians (NREMT, 2021) qualification examinations.

Given the low likelihood of prehospital childbirth experience, paramedic education programmes provide in-hospital clinical experience in labour and delivery/childbirth departments. This mandatory exposure is to make paramedic students more comfortable and competent when faced with an OB or childbirth situation in the prehospital setting.

It can be difficult to gain experience in OB situations, however, as hospital labour and childbirth units are unique centres for women's health and are highly sought after by students of various disciplines who need to gain experience in these areas before they complete their training. People in these disciplines include licensed practical nurses, registered nurses, advanced practice providers, medical students, residents, midwives and allied health professionals (which could include students from paramedic programmes).

During the course of paramedic education, CoAEMSP requires that each student completes a portfolio including the successful performance of specific skills and exposure to certain patient types. These may be accomplished in skills laboratory, in the field (ambulance or prehospital) or hospital settings. The portfolio is structured to provide the knowledge necessary to attain the skillset of an entry-level paramedic. When students have finished the education programme, these skills are verified by the NREMT through practical and theory qualification examinations for prehospital care providers in the United States.

The Fisdap Paramedic Readiness Exam version 3 (PRE3) and version 4 (PRE4) are summative, validated exams, and a student's success on the PRE3 or PRE4 is positively correlated with success on the NREMT paramedic qualifying exam (Page et al, 2004).

There is evidence to show that the number of patient contacts a paramedic student has is positively correlated to their performance on specific subsections of a summative exam (Wilfong et al, 2010). Additionally, preliminary research shows that success on qualifying examinations is enhanced by increased field patient contacts (Page et al, 2013; Oblak et al, 2017. However, Salzman et al (2007) examined paramedic student completion of recommended clinical experiences and found that only 30% of 1817 students completed 100% of the (then) recommended 10 live obstetric assessments, and that 57.7% of paramedic students had fewer than 50% of the recommended number of clinical contacts.

Considering that prehospital OB and childbirth cases are rare and have a high likelihood of complications, all paramedic students, without bias, should be given opportunities to increase their knowledge and test scores in these situations. Furthermore, educators should monitor students' progress in the OB/childbirth hospital setting to make sure they are obtaining the required number of experiences.

CoAEMSP (2019) recommends that students should have at least three skills laboratory experiences in which there is a normal childbirth and newborn care and an abnormal childbirth with newborn care. After a student demonstrates competency in the skills lab in those areas, they then have to perform the skills needed for four normal births with newborn care, and four abnormal births with newborn care in comprehensive skills laboratory scenarios or on a live patient during ambulance or in hospital labour and childbirth units (CoAEMSP, 2019).

Evidence indicates that male students tend to get fewer live birth experiences in labour and childbirth units during hospital clinical placements than their female counterparts. This is reflected by research that reviewed the experience of male and female medical students enrolled in an obstetrics and gynaecology clerkship. The data show that men had fewer experiences; they often felt their sex negatively affected them and that they were commonly refused an experience because of the patient's wishes (Chang et al, 2010). Later research showed that gender bias in a women's health unit can result in lower test scores related to the experience (Craig et al, 2013).

Despite the low frequency of prehospital childbirth and the high rate of complication in those cases, no studies have been completed that examine the correlation of field, skills lab or clinical experiences of obstetrics with paramedic student test scores in the United States.


Data and research

Fisdap is an online tool for prehospital medical training used by more than 85% of learning institutions accredited by CoAEMSP. It provides skills tracking, documentation and scheduling software as well as entrance, formative and summative exams for all levels of prehospital medical training.

De-identified, raw data from the Fisdap (2021) database can be used by local institution educators to track student progress and in larger research studies to evaluate for trends in student performance.

A retrospective review of Fisdap data collected between 1999 and 2018 was performed. Data were collected on paramedic students using the Fisdap learning management system with consent obtained at the time of enrolment.

The use of the data for this retrospective research was approved by the Inver Hills Community College Institutional Review Board in Minneapolis.

The data used for this research project had been de-identified by Fisdap before it was made available. Ethical approval for the project, via the exemption pathway, was approved (E/17/073).

Participant information

Student accounts and experiences that met the inclusion criteria include paramedic students who provided consent for research, had said they were male or female, and had completed the PRE3 or the PRE4.

Experiences of each student where the primary or secondary impression was recorded as ‘OB labor’ or ‘OB birth vaginal’ were then compared to the student's sex and experience type (hospital clinical, field or skills laboratory) and were then compared to that student's score on the OB section of the PRE3 or PRE4.

Outcomes and data

This study's primary purpose was to identify if higher numbers of student experiences correlated to higher test scores on the OB section of the Fisdap PRE3 or PRE4. The study's secondary outcome was to evaluate if a gender bias exists in experiences in general or in any of the clinical settings (field, clinical or skills laboratory).

Data were pulled from the Fisdap database; students had already been de-identified. Each student's information included their total number of field, clinical and skills laboratory birth experiences and also their initial test scores on OB section of the PRE3 or PRE4. The year when students were in education dictated whether they took the PRE3 test or its successor the PRE4.


All statistics and figures were computed using R (


This study include 12 090 paramedic students. In the PRE3 group, there were 2682 women and 5625 men. In the PRE4 group, there were 1285 women and 2498 men.

Women and men both had a mean score of 0.76 on the OB section of the PRE3. The mean OB section scores on the PRE4 were 0.79 for women and 0.77 for men. There was no meaningful difference in OB test scores by sex.

Although women and men scored approximately the same on the PRE3 and PRE4 OB sections, women saw more births and women in labour during their shifts. Tables 1 and 2 provide the mean number of births or labour seen by student gender and shift type for the PRE3 and PRE4, while the mean and standard deviation of OB section scores on the PRE3 and PRE4 are provided in Table 3. On the PRE3, female students saw on average 4.61 births or women in labour, compared to 4.03 for their male counterparts students. On the PRE4, female students saw on average 4.83 births or women in labour, while male students saw 4.26 births or women in labour.

Shift type
Gender N Field Clinic Lab Total
NA 1675 0.41 3.76 0.1 4.31
Female 2682 0.46 3.92 0.23 4.61
Male 5625 0.39 3.43 0.21 4.03
TOTAL 9982 0.41 3.62 0.20 4.23

Shift type
Sex n Field Clinic Lab Total
NA 435 0.31 3.71 0.18 4.21
Female 1285 0.41 4.06 0.36 4.83
Male 2498 0.38 3.54 0.32 4.25
TOTAL 4218 0.38 3.72 0.32 4.42

Exam Female Male
PRE3 n=2682 n=5625
Mean=0.76 Mean=0.76
SD=0.11 SD=0.11
PRE4 n=1285 n=2498
Mean=0.79 Mean=0.77
SD=0.10 SD=1.10

n=number of students; SD=standard deviation

Of students who took the PRE3, their experiences occurred predominantly in hospital, and women on average saw 0.49 more births per shift (women=3.92; men=3.43). This same pattern was seen in students who took the PRE4, where women on average saw about 0.52 more births per hospital shift than men (women=4.06; males=3.54)

Although female students tended to see more births or labour during their shifts, the number of births or labour seen was not correlated with PRE3 or PRE4 OB scores. Figures 18 show the correlation of the PRE3 and PRE4 scores with births or labour seen by shift type. The correlation coefficient was in the 0.0–0.06 range, as can be seen in the flat lines in the figures. Therefore, the increasing the number of live births or women in labour observed by students did not lead to an increase in OB scores on the PRE3 or PRE4.

Figure 1. PRE 3 hospital
Figure 2. PRE 3 field
Figure 3. PRE 3 skills laboratory
Figure 4. PRE 3 total
Figure 5. PRE 4 hospital
Figure 6. PRE 4 field
Figure 7. PRE 4 skills laboratory
Figure 8. PRE 4 total

Conclusion and discussion

Female paramedic students consistently have more OB experiences in clinical settings than their male counterparts. However, there are no differences in field or skills laboratory OB experiences and there is no meaningful correlation between the total number of OB experiences and subsequent scores on the OB section of the PRE3 and PRE4.

Implications for education and research

Stakeholders in EMS education programmes should be aware of and investigate ways in which bias is present within their students' clinical experiences and how to compensate for or resolve this bias.

This research raises questions on bias in clinical experience of paramedic students compared to students of other disciplines (e.g. medicine, nursing and advanced practice providers).

Further research is necessary to determine the validity of this claim and to what degree it potentially exists.

Past research, including this study, shows that OB emergencies that present in the prehospital arena are high-acuity, low-frequency events (Verdile et al, 1995; McLelland et al, 2014; Flanagan et al, 2017).

All traditional prehospital provider (emergency medical technicians, advanced emergency medical technicians and paramedics) complete training on these emergencies and are expected to manage them autonomously, yet NREMT qualification standards do not guarantee that their knowledge and skills of OB emergencies will be evaluated.

Other high-acuity, low-frequency skills such as airway management have been recognised and addressed by providing alternatives and resources to prevent poor test results. However, given the physiologic nature of OB emergencies, there are no such alternatives for prehospital providers.

Given this history and present data, further research should be conducted to evaluate if curricula for students and providers are adequate in providing education and if current evaluation strategies ensure providers can autonomously manage these situations.

Study limitaions

This research is based on self-reported data.

While students are required to log and document their OB experiences, objective evaluation of the quality of these experiences is difficult and may vary because of internal and external factors. Experiences in a hospital can range from full assistance in the birthing process to being allowed only to observe from a doorway for a limited part of the process.

Additionally, the researchers had no means in which to evaluate a student's past experience with OB emergencies and childbirth before their documented clinical experiences. It could be inferred that previous knowledge and experience with OB emergencies and childbirth could alter a student's experience and their scores; however, no data exist to support this.

There was no way to evaluate the instructor's confidence in the subject matter during the patient care experience. It stands to reason that a higher quality clinical experience will be provided when the instructor or preceptor is well versed and experienced in prehospital OB emergencies.

As the retrospective data used are from all schools who use Fisdap, there is no way to evaluate the didactic portion of the curricula (depth, breadth, emphasis from instructors or time spent) and the effect of these on OB section scores. Additionally, the sequence of didactic, skills laboratory, clinical/field experiences and examination times may vary between programmes.

Future paramedic education

Bias can affect the education of students and should be closely monitored and compensated for to meet the educational need of students.

This study shows that female paramedic students are more likely to see live births than their male counterparts, which may put male students at an unfair disadvantage in their paramedic education.

While this finding shows no effect on test scores, it does show that future investigations should be conducted to determine if there are other ways in which this bias creates a disadvantage to some groups compared with others.

Future research

Considering that there is no meaningful difference in correlation between PRE3 and PRE4 test scores and OB experiences for women and men, the incidents of OB contacts is higher for women; further research should be conducted to see if the number of OB contacts recommended has any cognitive significance at all. Does observing 2–4 live births in the controlled setting of a labour and childbirth room equate to the experience of an out-of-hospital birth attended by only an ambulance crew?

Future research should focus on simulation as a means of providing future paramedics with the experience necessary to handle these types of calls. This research should focus on numbers of simulations and environments, and requires rigour.

Key points

  • Prehospital child births are a low-frequency occurrence with high risk for complication, morbidity and mortality
  • All prehospital providers in the United States receive some initial training on the management of these emergencies
  • While female paramedic students experienced more child births in the hospital than their male counterparts, this did not translate into a meaningful difference in summative test scores
  • On average, paramedic students scored less than 80% on the FISDAP OB emergencies summative, cognitive exam
  • Births were uncommonly attended by paramedic students in both the ambulance and skills laboratory settings
  • Other factors, such as a student's past knowledge or experiences with OB emergencies, a preceptor's confidence in the subject and/or the depth of didactic material, could theoretically affect summative test scores; however, future research should be carried out to evaluate this claim
  • CPD Reflection Questions

  • Reflect on your own experiences with prehospital emergencies
  • What can be done to improve the knowledge of OB emergencies by prehospital care providers and stakeholders?
  • What are findings that may indicate that a bias is present within the EMS workforce or EMS education?