Abstract
Objective To determine what factors individual physicians in a remote northern Saskatchewan community consider when advising patients on an obstetric delivery location.
Design Semistructured interviews.
Setting La Ronge, a remote northern Saskatchewan community.
Participants Eleven family physicians providing full-scope care in a remote medical clinic.
Methods Each physician at the only medical clinic in the area was sent an email in February 2017 inviting them to be involved in the study. Interviews were conducted between February and April 2017 and were audiorecorded and manually transcribed. The transcribed interviews were returned to participants for their review and additional input. Saturation was reached after 9 interviews, with 2 further interviews being conducted after saturation for a total of 11 interviews. Inductive thematic analysis was undertaken following the interviews.
Main findings Patient choice was an important factor in the discussion about delivery location. Themes that evolved from physician consideration on delivery location included benefits of local delivery, local resources, selection of low-risk pregnancies, physician and nursing skills, and patient choice.
Conclusion Family physicians should provide patients with all potential options for delivery location and support the decision made with the patient.
People living in rural and remote parts of Canada face barriers to accessing maternity care.1-4 Factors associated with obstetric care outflow from one’s home community include parity, high-risk pregnancy, availability of local services, and distance to a care centre.5 The Society of Obstetricians and Gynaecologists of Canada (SOGC) and the National Council of Indigenous Midwives advocate that rural obstetric care should be supported and promoted.1,3,6,7 However, a number of challenges exist. Closure of rural maternity services has been occurring in Canada as a result of insufficient human resources, regionalization, medical specialization, and cost-cutting efforts.8-11 There is also a recognized shortage of rural practitioners, including GP anesthetists and rural obstetricians.12,13
Psychosocial needs of mothers are better met when they are able to deliver in their home communities.14 Researchers examining the psychological implications of relocating to give birth have found an increase in stress and anxiety along with feelings of powerlessness and confusion.15,16 Guidelines and position statements emphasize that mothers should have a say in how their care is delivered.1,2 At home, mothers and their newborns have greater access to family members and caregivers, traditional ceremony, and community celebration.9,17
Pregnant individuals consider many factors when deciding where to deliver. One study found that a patient’s beliefs were central in this decision, compared with personal and systemic factors, regardless of how much one knew about their local obstetric services.18 Another study found women considered access to medical services, proximity to their home community, and perceptions of medical care providers in their choice of delivery location.19 Both studies found the recommendations from family physicians were not as important as patients’ preferences, although their conversations with family physicians may be taken into consideration.18,19 Despite this, how a physician counsels a patient about delivery location might be expected to have an impact on the patient’s decision and, by extension, on the delivery rates in a community.
The La Ronge Health Centre in northern Saskatchewan serves approximately 16,000 people in the geographic area, with family physicians providing full-scope care. The closest specialist service, including the closest surgical suite, is 240 km away. The number of newborns delivered per year at the centre has been steadily decreasing, now 40 per year compared with 3 times that many 27 years ago.20 This is despite the population having one of the highest birth rates in the province, with around 400 births per year from women in the area according to data from 2011 and 2014.21,22 Several authors of this manuscript previously interviewed individuals who were pregnant to get a better understanding of how patients are choosing their delivery location.19 The authors then wanted to evaluate what factors physicians considered when advising patients on delivery location during antenatal clinic visits.
Thus, our research question was “What factors do individual physicians in a remote northern Saskatchewan community consider when advising patients on delivery location?”
METHODS
Participant recruitment was undertaken in February 2017 by sending 2 email invitations using the physician listserv in Saskatchewan, spaced approximately 2 weeks apart. All 14 family physicians at the La Ronge Medical Clinic were invited to participate, given they all counsel pregnant patients during their antenatal visits on where to deliver, and provide obstetric services. The goal was to interview at least half of the physicians or obtain 2 more interviews after information saturation was achieved, whichever number was greater. Participants were engaged in individual semistructured interviews lasting between 10 and 60 minutes. Interviews were conducted in person in a private setting by one of the researchers (N.M. or T.T.). Interview structure and questions were designed to explore in detail the individual counselling practices of physicians, including the factors they commonly consider when counselling patients during prenatal visits about location of delivery. The interviews were conducted between February and April 2017 and were audiorecorded and manually transcribed by the researchers. Hard copies of individual transcripts were returned to the participants for their review and additional input or editing before data extraction. An inductive thematic analysis was conducted to evaluate the data. Coding of each transcript was manually conducted by a single researcher (N.M.). Two researchers (N.M. and T.T.) then reviewed the coded data extracts separately to identify themes within the data. The themes identified by the separate researchers were then collated for refinement and review.
Ethics approval was obtained from the University of Saskatchewan Behavioural Research Ethics Board (Beh-REB 17-447).
FINDINGS
All 14 physicians agreed to be interviewed, although saturation was reached after interviewing 9 family physicians. Two additional interviews were conducted following saturation for a total of 11. Themes that evolved from the data were benefits of local delivery, local resources, selection of low-risk pregnancies, physician and nursing skills, and patient choice.
Benefits of local delivery
The many positive aspects of local delivery are not confined to any specific category. La Ronge Medical Clinic physicians emphasized the well-known advantages of social, psychological, physical, and cultural support when delivering closer to one’s home community. They also mentioned the enjoyment that comes from providing obstetric care. One physician emphasized the benefit of birth taking place at the local hospital:
If babies are no longer being born in the community or in the hospital, there will still be people dying. So there becomes an imbalance there where there is only grief associated with the hospital—with health care—and not the celebration. I think communities that lose rural obstetrics struggle with that. The hospital ends up becoming a place for the ill and dying.
Local resources
Available options for intrapartum analgesia were a topic commonly discussed during antenatal counselling about delivery location. With no epidural services, physicians thought it important for patients to know that pain control could be managed by other means. Not surprisingly, many physicians raised the issue of our lack of cesarean delivery capability. Concerns centred around fears of potential poor maternal and fetal outcomes in the event a cesarean delivery was needed but delayed by transportation time. The point was also raised conversely, in which pregnant individuals who are referred to tertiary care may be at higher risk of unnecessary obstetric intervention. Physicians regularly explain to patients during the prenatal period that if intrapartum concerns arise, emergency evacuation from La Ronge via road or air ambulance may be required: “There’s nothing worse than feeling helpless with a woman this far away from an OR [operating room]. People went into this job to help others, and would hate to put patients in a situation where they wouldn’t have the best outcome.”
Selection of low-risk pregnancies
To mitigate the risk of requiring transfer, physicians actively identify low-risk patients for delivery in La Ronge during the prenatal period and refer everyone else to the tertiary care centre of their choice. However, opinions vary on the criteria for a low-risk pregnancy. Perhaps the most controversial risk factor is nulliparity. Some physicians quote an unwritten local policy of referring all nulliparous patients, while others believe nulliparity alone is not an adequate reason for referral. The rationale for referring nulliparous individuals stems from the thought they are more likely to require advanced obstetric intervention than their multiparous counterparts who have delivered vaginally before and without complication. Physicians noted referring nulliparous patients seems to create the expectation among patients that once referred, they will be referred for all their future deliveries, which supports the idea they will receive better obstetric care at tertiary care centres.
I must say I don’t use a formal rating scale for [screening for low-risk patients]; it is more of a gut feeling based on certain parameters. So the definition of low risk is a bit fluid at times. It all depends on what is going to be safe for us, for the patient, and also for the staff.
The problem [with screening] is that we all have different opinions, obviously. We all have different comforts in what constitutes low risk.
Physician and nursing skills
La Ronge Medical Clinic physicians believed if local delivery numbers declined, there was a risk that physician and nursing obstetric skills would erode over time. Concerns were raised about current delivery numbers being too low already and younger family physicians who practise obstetrics or want to practise obstetrics may not be gaining the exposure and experience needed for remote obstetrics. Incidents were described in which practitioner discomfort led to transfer of individuals in labour. There was some fear that a lack of skill would lead to bad patient outcomes and subsequent litigation. A number of physicians expressed the hope that implementing educational strategies to address maintenance of obstetric skills could make up for low volume: “For a lot of physicians, confidence comes after competence, and so for me I think I require some ongoing simulations to maintain that confidence at least.” In addition, most physicians were receptive to the idea of exploring having a midwife or doula on an interdisciplinary team with the caveat that La Ronge Health Centre delivery numbers are likely currently too low to support the addition of one or both of these specific services.
Patient choice
La Ronge Health Centre family physicians generally believed patient preference was the most important factor when engaging in shared decision making regarding delivery location, but the decision should be informed by a realistic discussion of the risks and benefits of local delivery versus referral to a tertiary centre. Family physicians were concerned patients may not always have a clear view of the various factors that could influence their delivery experience. It was thought that pregnant individuals have many reasons for choosing a delivery location that should be explored. In general, physicians were extremely supportive of local delivery if it was chosen by the patient after a conversation.
If patients want to deliver in [the city] for whatever reason I’m not going to stop them. If they have their own personal reasons for that, I’m not going to persuade someone to deliver [locally] just because we feel that we should be delivering more patients here. I would love for there to be more deliveries in La Ronge but I’m not for making women deliver here against their wishes.
DISCUSSION
Despite supportive literature on the benefits of rural delivery1,9,17 and the SOGC’s support for rural obstetric care,2 the number of local deliveries per year in the remote community of La Ronge has declined. Physicians have a role to play to ensure patients are aware of the risks and benefits of delivering close to home. It is difficult to reconcile the known advantages of local delivery with the potential and perceived risks of not having emergency obstetric backup. The SOGC does not currently provide clear comprehensive guidance on for whom it is safe to recommend local delivery and for whom it is not. They suggest the following:
Low-risk pregnancies include primigravida and multigravida individuals without any significant medical or surgical (no previous Caesarean section) complications, term pregnancy (>37 weeks gestation), and singleton vertex pregnancy with no fetal anomalies that may be cared for appropriately with local resources.23
Other predictive processes have been created to aid in determining whether pregnancies are low risk, including by the Society for Maternal-Fetal Medicine24 and the Rotterdam Reproductive Risk Reduction score card.25 However, these tools do not consider the social aspects of delivering away from one’s home community. A study from Australia discusses the importance of the nonclinical risks and suggests including corporate risks, as well as social risks such as cultural, emotional, and financial risks, to the overall risk assessment.26 The SOGC supports something similar.2
For this study’s physician respondents, the availability of cesarean delivery is a major consideration when counselling patients about location for delivery. One study of rural hospitals in British Columbia in 2006 previously demonstrated that in hospitals with cesarean delivery capability, as many as 85% of pregnant individuals delivered locally, whereas fewer than 30% delivered locally in centres without these surgical services.8 It is clear that cesarean delivery is an important and life-saving intervention. What is less clear, however, is how greatly the importance of local cesarean capability should be weighed by patients and their physicians when deciding on delivery location during antenatal counselling. A 1998 report determined that 6% to 7% of women from northern Saskatchewan, compared with less than 4% of southern rural women, were transferred to an urban centre after they were initially admitted to a rural northern facility.20 It is not known whether these transfers ultimately required cesarean delivery or if having a rural surgical suite with GP anesthetists and GP surgeons would have decreased this transfer rate. Balancing these facts against the numerous advantages of rural delivery is difficult.
Safety and outcome data, in general, do not discourage rural deliveries.27 Similar obstetric outcomes may occur in rural hospitals even in the absence of cesarean delivery availability.28 Pregnant individuals from rural communities have been identified as less likely to require cesarean delivery and operative delivery and as being more likely to achieve spontaneous vaginal delivery.4 A study involving 150,000 births in British Columbia, Alberta, and Nova Scotia showed statistically equivalent obstetric outcomes for sites having cesarean delivery versus those without local access to surgical services.29 However, conflicting evidence exists. Data from northern Saskatchewan showed that the perinatal mortality rate was higher than the provincial estimate, although this difference was not statistically significant.22 Another study suggests perinatal death increases as distance from a centre with cesarean delivery capability increases, and overall there is a significantly higher rate of severe maternal morbidity (adjusted odds ratio 1.15, 95% CI 1.03 to 1.28) and neonatal morbidity outcomes (adjusted odds ratio 1.14, 95% CI 1.02 to 1.29) among those from rural communities.30
If rural communities hope to retain their obstetric services without the unlikely addition of surgical services, rural physicians need to objectively determine their comfort with risk to allow deliveries to continue there. The study physicians are now creating a formal risk assessment tool in collaboration with their urban obstetric partners to determine the criteria for prenatal referral, as well as patient handouts to discuss risks and benefits of rural delivery early in the pregnancy. Study participants considered nulliparity as an important factor in the discussion of where a patient could deliver. This likely comes from studies that have identified nulliparous individuals as having a higher risk of birth complications.31,32 However, as stated above, the SOGC indicates primigravida status can be considered low risk.23 The Rotterdam Reproductive Risk Reduction score card does list nulliparity as a risk, albeit in line with other risks such as smoking during the first trimester, taking over-the-counter medications, or being a part of a certain ethnic group, and not as an absolute contraindication to rural delivery.25 Considering this mixed guidance, the unwritten nulliparity policy referenced by the interviewees has been revisited in the study community and is now officially not to be considered an absolute contraindication to local delivery. The study community acknowledges that although nulliparity does come with risk, it alone may not offset the benefit of local delivery. However, this does not negate a complete social assessment, and nulliparity status may still contribute to an overall picture during discussions between physicians and prenatal patients. Other rural communities may benefit from standardizing an approach to the referral of pregnant individuals for specialist obstetrical care and clarifying who qualifies for attempting local delivery.
When obstetric care volume declines, physicians become concerned about keeping up their skills and feel frustrated that they are not able to deliver essential medical services. Despite this loss of confidence amid lower delivery volume, it has been shown that a high volume of deliveries is not necessarily needed to achieve good outcomes.33 The SOGC, the College of Family Physicians of Canada, and the Society of Rural Physicians of Canada agree, stating that “competence in obstetric care is not dependent on number of births attended annually.”34 There are nationally recognized education opportunities that have been shown to improve physician and nursing obstetric care.35 This was something the remote physicians in the study agreed would be useful and has been shown to have a benefit in the workplace environment and clinical outcomes. Improving remote physician confidence in their delivery skills may translate to a more encouraging discussion with patients to have them deliver closer to home.
Limitations
Limitations of the study design include the small number of participants and the inability to discern completely what is said in discussions with pregnant patients, instead relying on physicians to recount what they usually consider and discuss. Additionally, interviews with family physicians were conducted by family medicine residents who were supervised by the family physicians interviewed. Physicians may have altered their responses based on what they wanted the residents to be learning or not learning owing to social desirability bias.
Conclusion
The crucial factors for physicians to consider when deciding if remote delivery is appropriate are not well defined, nor is how the crucial factors should be weighted. Family physicians are aware of the benefits of local delivery, but apprehension remains. Guidance on whose pregnancy is low risk and can be delivered in a remote location, and educational opportunities to improve physician skills for remote delivery, may help address these concerns. In referring more pregnant individuals than may be warranted given the available evidence, remote physicians risk the continuing decline in number of local births and expose patients to the negative impacts of relocation for delivery.
Acknowledgment
The authors thank Dr Rhonda Bryce of the Department of Academic Family Medicine at the University of Saskatchewan for her valuable input in preparing this manuscript, and the physician participants for their time and knowledge.
Footnotes
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
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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