Abstract
Objective To explore the perspectives and preferences of pregnant women receiving prenatal care in a rural community regarding delivery location.
Design Exploratory qualitative research project.
Setting The La Ronge Medical Clinic in northern Saskatchewan.
Participants Pregnant women of any parity aged 18 years or older who attended the clinic for prenatal care from March 1, 2018, to March 31, 2019, were invited to participate. The closest obstetric and surgical services are 240 km away.
Methods This project was undertaken using semistructured interviews. The interviews were audiorecorded, transcribed, and analyzed using an inductive thematic analysis, taking into consideration both saturation and analyst triangulation. The investigators and researchers on this project were family medicine residents and faculty in a remote medical clinic.
Main findings The factors that played a substantial role in influencing the patients’ decisions regarding delivery location included access to medical services, proximity to home community, perceptions of medical care providers, and some unique features of local hospitals. The participants largely believed they maintained their autonomy in selecting their preferred delivery location while seeking input from their prenatal care providers and families.
Conclusion Pregnant women in this rural community consider many factors when deciding on their delivery location. These findings can be taken into consideration by physicians when discussing with their rural patients the risks and benefits of delivery in both rural and urban centres. Barriers to local delivery should be addressed, while maintaining a woman’s autonomy to choose where she gives birth.
Our elders speak about how the circle of life is not complete in many of our communities because they only have deaths, they don’t have births in the communities .... So they don’t have that balance of happiness and joy with the sadness of the passing of the person.
Dr Veronica McKinney1
The College of Family Physicians of Canada (CFPC), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the Canadian Association of Midwives advocate for the provision of obstetric care in a patient’s setting of choice, and as close to home as possible.2-4 Despite this, pregnant women from rural and remote communities often travel long distances to access obstetric services in larger urban centres.5-8 Many factors contribute to obstetric outflow in small communities, including regionalization of health services, closure of rural maternity services, health care worker recruitment and retention challenges, and patient preference.5-8
Research has been conducted in rural communities across British Columbia, Manitoba, northern Ontario, and the northern territories to understand the local women’s perspectives on delivery location.9-12 This work has identified several themes. Most notably, the process of leaving a home community is commonly associated with emotional, physical, and financial hardship.8 There is often considerable stress associated with traveling for care and a lack of support in the referral community.7,8,10 Women frequently experience loneliness and a sense of deeply missing their families.6,9 Several other concerns have also been described, such as difficulty with language barriers, problems understanding the adoption process, the fear of living with strangers as roommates, adjusting to different food, and boredom.10 It is also important to recognize that positive aspects of traveling to an urban centre for delivery have been identified. These include a sense of increased safety in case of complications, access to free services such as wireless Internet, and having a break from household chores.6,10
In August 2018, CBC News published an article titled “Women in northern and rural Sask. travel nearly 900 km to give birth.”1 This article informally captured many of the challenges faced by residents of northern Saskatchewan and brought awareness of this issue to the broader Canadian public. However, there remained a gap in the formal literature about this phenomenon.
La Ronge Medical Clinic is one of the larger centres in northern Saskatchewan and is serviced by full-scope family physicians. They also provide health care to many smaller communities in the north. Obstetric patients in these smaller communities need to travel to the family physician for delivery or to a tertiary centre for higher-risk deliveries. With a population density of 17 people per 100 km, compared with 165 people per 100 km in Saskatchewan as a whole,13 this presents challenges for patient transport. The closest specialist service, and the closest surgical suite, is 240 km away.
The number of babies delivered locally has been declining in this northern community, despite a stable overall birth rate from the local population,13 because many women are being referred to urban centres for delivery.14,15 This urbanization of deliveries is not specific to northern Saskatchewan. One report from the Canadian Institute for Health Information found that two-thirds of women in rural areas across Canada delivered in an urban hospital, and 21% of these women had to travel more than 2 hours to get there.16 This study explores the decision-making process of choosing a planned delivery location from the viewpoint of rural pregnant patients. By having a better sense of which factors women consider when deciding on delivery location, we can provide a more informed approach to prenatal consultations in an attempt to encourage local delivery while retaining patient autonomy.
METHODS
This study received ethics approval from the University of Saskatchewan Behavioural Research Ethics Board, and operational approval from La Ronge Medical Clinic and the La Ronge Population Health Unit.
This was a qualitative research study. The patients included were pregnant women receiving prenatal care at the medical clinic during the study period who were 18 years of age or older and deemed by the doctor providing prenatal care at the time of the visit to be medically competent to make their own health care decisions. Patients were not included in the study if they did not speak English, because of a lack of professional translation services.
Patient recruitment was purposive. Front-desk staff invited potential participants to join the study when the patients called to book their prenatal appointments, or when front-desk staff called patients to confirm their appointments. After their prenatal visit the participants met with the investigators, who explained the purpose and nature of the interviews, confirmed that participation was voluntary, and clarified that their decision to participate would not affect the quality of future medical care at the clinic. Women who chose to participate in the study were asked to review and sign a consent form. Women were offered an opportunity to opt out of seeing the residents conducting the research project for their future prenatal visits.
A minimum sample size of 15 was chosen for the initial analysis. A second round of interviews was then conducted, with an indeterminant sample size. Interviews would stop once 5 further interviews provided no new ideas on the topic, a process previously described.17
The interviews were conducted in person at the medical clinic by the resident investigators (G.R., K.D., N.M, T.T.) in a private setting following the participants’ prenatal visits. They varied in length from 5 to 25 minutes depending on participant responses. The interviews were structured to explore women’s preferences regarding delivery location. The interviews were audiorecorded, transcribed, and returned to the participants, if desired, for an opportunity to add, alter, and delete information from the transcript as appropriate. The participants were provided an opportunity to share any additional thoughts after the formal interview questions were completed.
Once all interviews were transcribed, the investigators undertook an inductive thematic analysis. To do this, 2 resident investigators (N.M., T.T.) separately examined each interview in an effort to provide analyst triangulation. Themes and subthemes present throughout the interviews were identified.
This research design was chosen for several reasons. Individual interviews allowed for opportunistic inclusion of participants who would have had difficulty scheduling a separate meeting outside of their prenatal visit, if for example a focus group had been conducted. It also allowed for anonymity, which is particularly important in a small community, and aimed to create a safe setting in which women were comfortable sharing their personal experiences. The open-ended nature of the questions was meant to promote responses that captured the diverse values and preferences that influence decisions around labour and delivery.
FINDINGS
Data were collected through 21 semistructured interviews with pregnant women at La Ronge Medical Clinic in northern Saskatchewan between March 1, 2018, and March 31, 2019. One participant withdrew from the study after the interview for personal reasons and is not included in the analysis. At the time of the study, all participants were living in what they considered a rural community. The gravida and parity status of our interviewees was not specifically solicited. However, some participants volunteered that information, and there was a variety of parity, including nulliparous women.
Several themes were identified regarding women’s opinions on delivering locally or traveling to an urban centre for delivery.
Patient autonomy
Most interviewees believed they were the ones making the decision on delivery location, rather than the physicians telling them where to deliver. At times there would be a discussion between the patient and the physician of the risks and benefits of delivering in the different locations, and the patient would take that into account before making their decision. Many times, however, interviewees reported that they had already made up their mind before the physician visit, sometimes with advice from their family and friends. Some physicians would still have a conversation about the decision, but other physicians would just accept the patient’s choice with no further discussion.
Access to medical care and services
The overarching theme mentioned by several interviewees was that larger centres provided peace of mind owing to the availability of interventions that could be accessed without delay in case of emergencies. This mostly included cesarean section capabilities, but also an option for epidural anesthesia and no shortages of blood products: “There is this kind of—this sense of security, that if anything happens, you don’t need to be flown down or ‘ambulanced.’”
Perceptions of clinical staff
Several study participants discussed the lack of trust in medical capabilities of local doctors and were certain that they would receive better medical care in larger centres. The lack of specialized physicians and dissatisfaction with generalists working in the local rural area were also identified: “If something goes wrong here, there are not that [many] doctors who can help.”
One participant indicated that the lack of training in obstetrics by local nursing staff influenced her decision to consider a larger centre for delivery. Others talked about their experiences in receiving care from the rural medical professionals and hospital staff as more personal, compared with a larger centre, since the women were already familiar with most of the health care workers. Some women, however, mentioned that this is a negative aspect of rural delivery, in that they do not want nurses and doctors that they know personally to see them at their most vulnerable.
Staying in community
Proximity to community and family was an important factor in making a decision on delivery location for most study participants. About half of the interviewees were aware of a period of prelabour confinement, which is loosely interpreted as moving to a city chosen for delivery 2 to 3 weeks before the due date. Many women stay in a hotel either alone or accompanied by a family member. Several interviewees identified this prolonged period of being away from community and family, and particularly being away from their children, as highly stressful and overwhelming. Being alone in an unfamiliar environment caused undue stress and anxiety. Many interviewees identified the cultural and spiritual importance of having family members in the delivery room itself. This is often only possible during a local delivery, as family members cannot financially or logistically get to the urban centre: “[I had] my daughter in the delivery room with me, and she was just a little one, and she did really good in there .... The family were right beside me when I delivered.”
Most interviewees also discussed how the travel itself (either antepartum or especially postpartum) negatively affected their experience: “The drive home was awful. It was awful. I was extremely hurt. I had a 4-hour drive, and it was a hard surface, and it was uncomfortable.”
This was compared with delivering in the community hospital: “You can step outside of the hospital and you’re in your own bed.”
DISCUSSION
The CFPC joint position statement on rural maternity care provides various recommendations pertinent to rural obstetric care, including that high-quality maternity care can be provided in rural community hospitals without surgical capability.2 In May 2019, the SOGC updated its previous statement, reiterating the same recommendation.4,18 The recent update is timely, providing guidance on identifying low-risk obstetric patients and defining expectations of safe maternal care in a level 1 health facility without cesarean section capabilities.4
While the support is evident from various organizations in favour of rural hospitals without surgical capabilities providing obstetric services, access to an emergency cesarean section was still a major factor in influencing the decision of our study participants on the location of their delivery. Literature suggests that in tertiary centres the rate of emergency cesarean sections is 0.67%, and recognizes that the indications for emergency cesarean section may unexpectedly arise in some low-risk women.19 A study looking at rural obstetric care in England in the United Kingdom estimated that with prescreening low-risk women for delivery in a rural centre, the rate of emergency cesarean sections was low, at 0.40%.20 In addition to these data, a recent large Canadian study found that perinatal and maternal outcomes were not negatively affected when women started their labour in a community centre without cesarean section capabilities.21 This evidence could potentially be used by medical professionals when discussing the risks and benefits of urban and rural delivery locations during prenatal consultations.
The negative impacts of leaving local communities to seek maternity care are well documented, and were echoed by most of our study participants, regardless of their planned delivery location. Understanding how travel outside of the local community for delivery affects pregnant women gives purpose to maintaining the provision of rural obstetric services, and could enhance prenatal consultations between pregnant women and their medical providers. Furthermore, literature suggests that diminished access to local rural maternity services leads to increased adverse perinatal outcomes, and shows that as distance to access these services increases, so does the severity of such outcomes.22
It is important to note that pregnant women in our medical clinic largely believed they maintained their autonomy in selecting their preferred delivery location. The current guidance from the SOGC underlines the importance of patient autonomy in decision making, particularly with regard to the preferred delivery location.4
The negative perceptions about rural obstetric care providers, such as midwives, nurses, nurse practitioners, and physicians, are concerning. To address this at an individual level, patient counseling could include exploration of these perceptions. At the community level, public information on the positive outcomes in rural obstetrics and ongoing obstetrics training activities may increase public confidence in local health care workers. In addition, collegial and supportive relationships between community hospitals and secondary and tertiary referral centres should be fostered and maintained. Perhaps by supporting each other, working together to create transfer protocols or develop an evidence-based approach to obtaining informed consent for local deliveries, we could address some of the negative perceptions voiced by some of our study participants toward rural practitioners.
Limitations
Our study had a number of limitations that should be recognized. One of the main limitations was interviewer familiarity with participants. Some of the participants were co-workers or patients of the interviewers. This may have influenced the participant responses or limited their comfort in sharing opinions with us. For example, if the participants believed they would be seeing us again for medical care at the clinic, they may have been hesitant to disclose concerns about the quality of local services in an attempt to preserve an amicable doctor-patient relationship. Another limitation of our study was the individual interview format. Throughout our interviews we noted that several of the participants addressed questions with responses such as “I don’t know.” The reason for this is unclear, but we believe it may have been partially because the participants were uncomfortable being put on the spot for an answer during a formal interview. Another possibility is that the wording of our interview questions made it unclear what we were asking. In retrospect, we think a focus group could have created more of a conversational atmosphere that better facilitated participant engagement and comfort with sharing their thoughts. Finally, our interviews were conducted in English only. Although this is the predominant language in the area, this may have excluded some participants.
We recognize that as practitioners in a rural community, we were biased toward encouraging patients to deliver rurally. We were not surprised that the lack of cesarean section capabilities would be a major concern for many interviewees. An emergency 2.5-hour intrapartum trip to get to a surgical suite is not a pleasant thought. We did not anticipate, however, the lack of trust that several interviewees had with the rural medical staff.
This is concerning to us, especially since we are a part of that team. We acknowledge that bias in this study, but it is also something that we need to examine further.
While centralization of surgical and obstetric services along with concentration of specialists in larger centres continues, there remains a stark need for and purpose to providing rural maternity services.18 Support and guidance from the CFPC, the SOGC, and provincial obstetric governing bodies, along with local collaboration, could not only help refine the selection of low-risk women for local delivery in a centre without surgical capabilities, but also better inform the evidence-based approach to prenatal consultations regarding both risks and benefits of a specific delivery location.
Conclusion
Pregnant women in this rural community consider many factors when thinking about their delivery location. These include access to medical care and services, leaving home and community, quirks of a community hospital, and perceptions of clinical staff. These findings can be taken into consideration by individual physicians when they provide prenatal counseling about labour and delivery. With increased awareness of patient perspectives, our health care professionals will be better prepared to respond to patients’ questions and concerns. More broadly, community-level policies can be developed to minimize the perceived barriers to giving birth within rural communities.
Notes
Editor’s key points
▸ Pregnant women from rural and remote communities often travel long distances to access obstetric services in larger urban centres. The women in this rural community considered many factors when thinking about their delivery location. These included access to medical care and services, leaving home and community, quirks of a community hospital, and perceptions about clinical staff.
▸ These findings can be taken into consideration by individual physicians when they provide prenatal counseling about labour and delivery. With increased awareness of patient perspectives, health care professionals will be better prepared to respond to patients’ questions and concerns.
▸ More broadly, community-level policies can be developed to minimize the perceived barriers to giving birth within rural communities.
Points de repère du rédacteur
▸ Les femmes enceintes des communautés rurales et éloignées doivent souvent parcourir de longues distances pour recevoir des services d’obstétrique dans un plus grand centre urbain. Dans cette communauté rurale, les femmes prenaient en considération de nombreux facteurs dans leurs réflexions sur le lieu de leur accouchement, notamment l’accès aux soins et aux services médicaux, l’éloignement de leur domicile et de leur communauté, les particularités d’un hôpital communautaire et leurs perceptions du personnel clinique.
▸ Ces constatations peuvent être prises en compte par chacun des médecins lorsqu’ils offrent du counseling prénatal au sujet du travail et de l’accouchement. En connaissant mieux les points de vue des patientes, les professionnels de la santé seront mieux préparés à répondre aux questions et aux préoccupations des patientes.
▸ Plus généralement, des politiques communautaires peuvent être élaborées dans le but d’atténuer les obstacles perçus à l’accouchement dans des communautés rurales.
Footnotes
Contributors
Dr Jeffrey David Connor Irvine was the lead investigator, helping with design, data collection, and manuscript preparation. Drs Guerman Rolzing, Kylie Doyle, Nicholas Martel, and Tamara Tsang were family medicine residents during the study. They helped with the project design, were the main interviewers, and helped with manuscript preparation. Dr Vivian R. Ramsden helped with the project design and manuscript preparation.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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