New approaches for rural maternity care

Access to rural maternity care—updated

Declining access to maternity care is a reality for many pregnant women living in rural areas, especially at great distances from urban or suburban centres. Owing to a recent combination of factors—concerns about safety and a scarcity of health resources—many rural maternity care centres face closure.¹ In tandem with this trend, some rural hospitals are reducing family physician privileges, including those related to maternity care. This combination of factors presents ongoing challenges to pregnant women in rural communities, their families, and their health care providers.

The consequences of traveling long distances to give birth have been reflected in the experiences of individual women and also affect the ability of their physicians and health care providers to ensure safe and supported delivery. Aboriginal and Inuit mothers are frequently among those forced to travel for maternity care. They might live in low-density population regions, or in geographically remote communities, and often lack the appropriate health facilities nearby.

Physicians and health care professionals who provide maternity care are aware that there are financial, psychological, and social consequences for women who must travel far from home to give birth.² The aboriginal and Inuit cultures in particular have a strong emphasis on family and extended support systems.^3–5 Separation from older children, partners, family, and friends at the time of birth is particularly stressful for new mothers. Additional worries about income loss and travel expenses add to her stress, as there will be costs for accommodation and food. Although the length of time away from home varies, periods of 3 to 4 weeks are not unusual; the mother might experience social and emotional isolation at the crucial time of giving birth.²

Rationale for updating the Joint Position Paper on Rural Maternity Care

The issue of rural maternity care continues to be problematic, and hospitals are reducing family physician privileges in rural areas. With that in mind, it was time to update the 1997 Joint Position Paper on Rural Maternity Care, developed by the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, and the College of Family Physicians of Canada.⁶ In the earlier paper, these organizations recognized ongoing issues about rural maternity care access. Fifteen years later, the original author organizations have been joined by 2 new partners, the Canadian Association of Midwives and the Canadian Association of Perinatal and Women’s Health Nurses, to develop an updated paper.⁷

Although the 1997 statement contains much that is pertinent to Canadian maternity care, changes have taken place and are addressed in the new statement. Most important, since 1997, evidence supports that rural maternity care, with or without surgical backup, can be safely achieved.^5,8 Complementary evidence suggests that morbidity and mortality increase with the distance that women must travel from home to give birth.^9,10 New developments have also taken place in collaborative models of maternal care, and the range of skills and experience of physicians, perinatal nurses, and midwives can contribute substantially to the resources that are available.

Recommendations for a better approach

Although the issues of maternal care in rural and remote areas are not new, the question remains: How can family physicians and maternity care professionals meet these ongoing challenges in an innovative and effective manner? The updated joint position paper supports the retaining and restoration of birth in aboriginal, rural, and remote communities, and recognizes the importance of the social and cultural context in maternity care. Its key recommendations include details about the role of maternity care teams, the skills and personnel that should be available, considerations about what constitutes the norm in professional training, and the needs of health care professionals in a continuous upgrading of their skills.

Rural in the context of maternal care has no fixed definition; it might refer to a remote area or regions of low population density closer to urban or suburban centres.¹¹ Given the wide variation in the use of the term rural and the areas served, many different models of care are possible. There is no expectation that all communities or regions will be able to support all aspects or levels of maternity care; the delivery of care to women and children must be sustainable and matched by the community’s resources.

High-quality care close to home comes in different forms. Rural family physicians, nurse practitioners, midwives, and registered nurses might maintain solo practices or work together in collaborative care practice models. Family physicians often act as leaders of these teams in which all team members are professionals with enhanced maternity care skills, and physicians with additional training and skills in obstetrics, surgery, and anesthesia can play an important role in this context. Collaborative care practice models constitute one method of ensuring high standards of care and patient safety.

The development of interdisciplinary teams has been a promising response to the current environment of decreasing resources. However, as a new approach to service delivery, maternity care teams require collaboration, dialogue, and attention to the groundwork of determining scopes of practice and establishing clear roles for all team members. These teams continue to require the support of specialist colleagues in obstetrics and gynecology, surgery, and anesthesia. With appropriate backup and support from specialist colleagues, all levels of care can be provided for pregnancy and delivery in rural communities.

Each discipline contributing to rural maternity care must focus on appropriate competencies for prenatal, intrapartum, and newborn care, but must also prepare its members for active participation in multidisciplinary, collaborative practices. Family medicine residents must be competent in supporting uncomplicated vaginal birth,¹² and opportunities for additional training in enhanced skills, including cesarean section, must be available.

Ongoing education, and the opportunity to renew and update skills, is essential for all health professionals working in rural areas. Family physicians who acquire enhanced skills in maternity care should be recognized and supported by national organizations and accrediting bodies. Fair compensation for provision of these services should also be provided through updated funding models, and support should be available for the additional costs of rural training. Newer models of continuing education and professional development can offer team members opportunities for their specific teams and communities. Quality of care and patient safety can be improved by this approach.

Safe, high-quality rural maternity care within communities is possible. Successful implementation of a new model will require teamwork, the appropriate resources and funding supports, and improved skills for family physicians and their colleagues.