Alone on the Roadside: Midwives Reveal the Hidden Strain of Emergency Birth Transport in Norway

When a pregnant woman in Norway goes into labour far from a birthing facility, official guidelines are clear: if the journey to hospital will take more than 90 minutes, she should travel by ambulance, accompanied by a midwife or a general practitioner. That regulation exists for good reason. Births that happen before arrival at a maternity unit, known in the medical literature as born-before-arrival or BBA births, are associated with adverse pregnancy outcomes, and the women who experience them often describe them as chaotic and dramatic. Ambulance personnel themselves have reported feeling unqualified to handle these emergencies. Yet until now, remarkably little attention has been paid to the professionals who sit beside labouring women in the back of those ambulances: the accompanying midwives themselves.

A new qualitative study published in BMC Health Services Research by Tone Engen, Leni Stavø Johansen, Kathrine Hågensen and Eline Skirnisdottir Vik offers the first in-depth look at how these midwives experience their unusual and demanding role. The researchers conducted individual, semi-structured interviews in the autumn of 2022 with eight midwives experienced in accompaniment transport services in Norway. The interview data were analysed using systematic text condensation, a rigorous qualitative method developed by Kirsti Malterud that involves systematic reading, coding, grouping and condensing of meaning units into themes. The result is a nuanced portrait of a service that sits at the intersection of emergency medicine, midwifery and health policy, and that has been shaped profoundly by the centralisation of maternity care.

The context is essential to understanding why this study matters. Across Norway, as in many other countries, maternity services have been consolidated into fewer, larger units in the name of quality and safety. But centralisation has a geographic cost: it lengthens the travel distances between women’s homes and the labour wards where they are meant to give birth. In a country of vast distances, mountains, fjords and long winter roads, that cost is measured in hours. For some women, the journey to hospital is long enough that labour simply cannot wait, and the birth happens en route, at home, or on the roadside. These are precisely the situations the accompaniment service was designed to mitigate, by putting a qualified birth attendant in the ambulance alongside the woman.

The analysis of the interviews produced four main findings, and the first is perhaps the most striking: decision-making in isolation. The midwives described often feeling alone in emergency situations. When a labouring woman’s condition changes in the confined space of an ambulance moving through remote terrain, the accompanying midwife may be the only birth expert present, forced to make consequential clinical judgements without colleagues at her side and with limited backup. This sense of professional solitude, the researchers found, is a defining feature of the accompaniment role, and it points to a gap between the clinical reality of roadside birth and the support structures currently available to the professionals who provide it.

The second finding, however, complicates any simple narrative of vulnerability. The midwives expressed a strong professional identity, seeing themselves as essential in providing qualified care during transport. In other words, the very expertise that makes them indispensable also anchors their confidence. They understood that without a midwife in the ambulance, a woman delivering before arrival would be attended only by personnel who, as previous research and the study’s background note, feel unqualified for obstetric emergencies. The midwives’ sense of themselves as the qualified presence in a high-stakes situation emerged as a core element of how they make sense of a role that few of their colleagues ever experience.

The third finding shifts the lens from individual emergencies to the organisational environment that surrounds them. The midwives reported that the uncertainty of what might happen during a shift was experienced as stressful and constraining. Unlike a hospital labour ward, where workload is visible and resources are at hand, an accompaniment shift can unfold in unpredictable ways: a straightforward transfer, a precipitous roadside delivery, or hours of waiting and travel. The midwives also questioned whether policymakers understand the impact of centralisation, a pointed critique suggesting that the people designing maternity systems may be underestimating the practical and psychological burden that longer transport distances place on both women and staff.

The fourth finding captures the emotional duality of the work. All of the midwives acknowledged the risks associated with born-before-arrival births, which the literature links to worse outcomes for mothers and babies. Yet they also recounted that uncomplicated BBA births could be empowering experiences. Some described roadside births as empowering and unique, moments of extraordinary professional meaning even amid demanding circumstances and feelings of isolation. This ambivalence, risk and reward intertwined, is precisely what makes the accompaniment role so difficult to categorise within conventional health service planning, and so important to understand on its own terms.

The study’s conclusions carry practical weight. The researchers suggest that accompaniment services require cross-professional collaboration and strong, easily accessible support systems. That recommendation follows directly from the findings: if midwives feel alone in emergencies, the answer lies in building better connections between the ambulance crew, the midwife, receiving hospitals and on-call obstetric expertise. If the uncertainty of shifts is stressful, the answer lies in organisational planning that acknowledges the unpredictable nature of the work. And if policymakers do not grasp the consequences of centralisation, the answer lies in bringing the lived experience of these midwives into the rooms where maternity policy is made.

Methodologically, the study is small but focused, and its design reflects the exploratory nature of the question. Eight participants is a modest sample, but for a qualitative study of a highly specialised role, depth matters more than breadth, and the systematic text condensation approach provides a transparent, auditable path from raw interview text to the four themes. The study was assessed by the Norwegian Centre for Research Data and by the research ethics department at the Western Norway University of Applied Sciences, and it adhered to the Personal Data Act and the General Data Protection Regulation. All participants gave informed consent, which they reiterated during the interview sessions. The authors declare no competing interests, and the work received no dedicated funding.

What emerges from this research is a vivid reminder that health service reorganisation is never just a matter of maps and budgets. When maternity units consolidate, the ripple effects reach into ambulance bays, mountain roads and the private, intense space where a woman gives birth before she reaches help. The midwives who accompany those women occupy a role that is simultaneously routine and extraordinary, isolating and empowering. Their testimony, gathered in this study, suggests that the safety of long-distance labour transport depends not only on the presence of a qualified professional in the ambulance, but on the systems of support, collaboration and policy understanding that surround her. As centralisation debates continue across rural health systems worldwide, the experiences of these Norwegian midwives offer a rare, ground-level view of what prolonged travel distances really mean, and a clear signal that the people who catch babies on the roadside deserve stronger backup than they currently have.

Subject of Research: Midwives' experiences accompanying women in labour during emergency transport in Norway

Article Title: Midwives accompanying women in labour during transport: a qualitative study

Article References: Engen, T., Johansen, L. S., Hågensen, K., & Vik, E. S. (2026). Midwives accompanying women in labour during transport: a qualitative study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15772-9

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15772-9

Keywords: midwifery, born before arrival, maternity care centralisation, ambulance transport, qualitative research, Norway, health services research, obstetric emergencies, labour transport, professional isolation, systematic text condensation, rural health