Exploring how pregnant women in a remote northern community select a delivery location

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.

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.