Jude Kornelsen

Distance matters: a population based study examining access to maternity services for rural women

BackgroundIn the past fifteen years there has been a wave of closures of small maternity services in Canada and other developed nations which results in the need for rural parturient women to travel to access care. The purpose of our study is to systematically document newborn and maternal outcomes as they relate to distance to travel to access the nearest maternity services with Cesarean section capabililty.MethodsStudy population is all women carrying a singleton pregnancy beyond 20 weeks and delivering between April 1, 2000 and March 31, 2004 and residing outside of the core urban areas of British Columbia. Maternal and newborn data was linked to specific geographic catchments by the B.C. Perinatal Health Program. Catchments were stratified by distance to nearest maternity service with Cesarean section capabililty if greater than 1 hour travel time or level of local service. Hierarchical logistic regression was used to test predictors of adverse newborn and maternal outcomes.Results49,402 cases of women and newborns resident in rural catchments were included. Adjusted odds ratios for perinatal mortality for newborns from catchments greater than 4 hours from services was 3.17 (95% CI 1.45-6.95). Newborns from catchments 2 to 4 hours, and 1 to 2 hours from services generated rates of 179 and 100 NICU 3 days per thousand births respectively compared to 42 days for newborns from catchments served by specialists.ConclusionsDistance matters: rural parturient women who have to travel to access maternity services have increased rates of adverse perinatal outcomes.

Safety and Community: The Maternity Care Needs of Rural Parturient Women

OBJECTIVE To investigate rural parturient womens experiences of obstetric care in the context of the social and economic realities of life in rural, remote, and small urban communities. METHODS Data collection for this exploratory qualitative study was carried out in 7 rural communities chosen to represent diversity of size, distance to hospital with Caesarean section capability and distance to secondary hospital, usual conditions for transport and access, and cultural and ethnic subpopulations. We interviewed 44 women who had given birth up to 24 months before the study began. RESULTS When asked about their experiences of giving birth in rural communities, many participants spoke of unmet needs and their associated anxieties. Self-identified needs were largely congruent with the deficit categories of Maslows hierarchy of needs, which recognizes the contingency and interdependence of physiological needs, the need for safety and security, the need for community and belonging, self-esteem needs, and the need for self-actualization. For many women, community was critical to meeting psychosocial needs, and women from communities that currently have (or have recently had) access to local maternity care said that being able to give birth in their own community or in a nearby community was necessary if their obstetric needs were to be met. CONCLUSION Removing maternity care from a community creates significant psychosocial consequences that are imperfectly understood but that probably have physiological implications for women, babies, and families. Further research into rural womens maternity care that considers the loss of local maternity care from multiple perspectives is needed.

Decision Making in Patient-Initiated Elective Cesarean Delivery: The Influence of Birth Stories

Patient-initiated elective cesarean delivery is emerging as an urgent issue for practitioners, hospitals, and policy makers and for pregnant women. This exploratory qualitative study looks at the birth stories and cultural knowledge that women use to inform the decision about an elective cesarean without medical indication. Data collection consisted of exploratory qualitative in-depth interviews with 17 primiparous women in British Columbia, Canada. Interviews revealed the influence of socially circulated birth stories and cultural narratives on their attitudes towards mode of delivery. Participants included in their decision making process both medical information and informal birth stories that were technologically inclined and confirmed their preference for cesarean delivery. Results indicate that women who participated in this study drew heavily from social and cultural knowledge in forming their decision to give birth by patient-initiated elective cesarean delivery. Although the numbers of women who request a cesarean delivery for social reasons is still small, the persuasive influence on parturient women of positive cesarean stories and negative vaginal stories must be considered. Care providers and childbirth educators need to become familiar with the social influences impacting womens decisions for mode of delivery so that truly informed choice discussions can be undertaken.

Stress and anxiety associated with lack of access to maternity services for rural parturient women.

OBJECTIVE The objective of this study is to compare the level of stress and anxiety between women resident in communities with different degrees of access to local maternity services. DESIGN   Cross-sectional survey. SETTING Fifty-two communities across rural British Columbia with different levels of access to maternity care services (ranging from no services to local specialist obstetrician). PARTICIPANTS A total of 187 women, 40 of whom were from communities with no local access to services. MAIN OUTCOME MEASURES Stress score on the R ural Pregnancy Experience Scale including financial and continuity of care subscales. RESULTS Parturient women who had to travel more than one hour to access services were 7.4 times more likely to experience moderate or severe stress when compared to women who had local access to maternity services. CONCLUSIONS Lack of access is strongly associated with stress in rural parturient women.

The geography of belonging: The experience of birthing at home for First Nations women ☆

The number of rural hospitals offering maternity care in British Columbia has significantly declined since 2000, mirroring trends of closures and service reductions across Canada. The impact on Aboriginal women is significant, contributing to negative maternal and newborn health and social outcomes. The present qualitative case study explored the importance of local birth for Aboriginal women from a remote BC community after the closure of local maternity services. Data collection consisted of 12 interviews and 55 completed surveys. The average participant age was 32 years old at the time of the study. From the perspective of losing local services, participants expressed the importance of local birth in reinforcing the attributes that contributed to their identities, including the importance of community and kinship ties and the strength of ties to their traditional territory.

Planning the optimal level of local maternity service for small rural communities: A systems study in British Columbia

OBJECTIVES To develop and apply a population isolation model to define the appropriate level of maternity service for rural communities in British Columbia, Canada. METHODS Iterative, mathematical model development supported by extensive multi-methods research in 23 rural and isolated communities in British Columbia, Canada, which were selected for representative variance in population demographics and isolation. Main outcome measure was the Rural Birth Index (RBI) score for 42 communities in rural British Columbia. RESULTS In rural communities with 1h catchment populations of under 25,000 the RBI score matched the existing level of service in 33 of 42 (79%) communities. Inappropriate service for the rural population was postulated and supported by qualitative data available on 6 of the remaining 9 communities. CONCLUSIONS The RBI is a potentially pragmatic tool in British Columbia to help policy makers define the appropriate level of maternity service for a given rural population. The conceptual structure of the model has broad applicability to health service planning problems in other jurisdictions.

Does Distance Matter? Increased Induction Rates for Rural Women Who Have to Travel for Intrapartum Care

OBJECTIVES Although there has been a devolution of local rural maternity services across Canada in the past 10 years in favour of regional centralization, little is known about the health outcomes of women who must travel for care. The objective of this study was to compare intervention rates and outcomes between women who live adjacent to maternity service with specialist (surgical) services and women who have to travel for this care. METHODS The BC Perinatal Database Registry provided data for maternal and newborn outcomes by delivery hospital for 14 referral hospitals (selected across a range of 250-2500 annual deliveries) between 2000 and 2004. Three hospitals were selected for sub-analysis on the basis of almost complete capture of the satellite community population (greater than 90%) to avoid referral bias. RESULTS Women from outside the hospital local health area (LHA) had an increased rate of induction of labour compared with women who lived within the hospital LHA. Sub-analysis by parity demonstrated that multiparous women had increased rates of induction for logistical reasons. CONCLUSION Rural parturient women who have to travel for care are 1.3 times more likely to undergo induction of labour than women who do not have to travel. Further research is required to determine why this is the case. If it is a strategy to mitigate stress incurred due to separation from home and community, either a clinical protocol to support geographic inductions or an alternative strategy to mitigate stress is needed.

The Meaning of Patient Experiences of Medically Unexplained Physical Symptoms

Current diagnostic models in medical practice do not adequately account for patient symptoms that cannot be classified. At the moment, when all known diagnostic possibilities have been excluded, physicians—and patients—confront uncertainty in diagnosis, which gives rise to the label of Medically Unexplained Physical Symptoms (MUPS). This phenomenological study, conducted by two research teams in two geographic locations, sought to explore patients’ experiences of prolonged uncertainty in diagnosis. Participants in this study described their experiences with and consequences of MUPS primarily in relation to levels of acuity and acceptance of uncertainty, the latter loosely correlated to length of time since onset of symptoms (the longer the time, the more forbearance participants expressed). We identified three experiential periods including the active search for a diagnosis, living with MUPS, and, finally, acceptance/resignation of their condition. Findings point to the heightened importance of the therapeutic relationship when dealing with uncertainty.

The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth.

BackgroundAvailable birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place.MethodsIn this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students’ t tests and ANOVA for categorical variables and correlational analysis (Pearson’s r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys.ResultsMedian favourability scores on the PAPHB–m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth.ConclusionsIncreasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

Is Local Maternity Care an Optional Service in Rural Communities

There has been a precipitous decline in the number of rural communities across Canada providing local maternity care. The evidence suggests that the outcome for newborns may be worse as a result. There is also an emerging understanding of the significant physiological and psychosocial consequences for rural parturient women. Because they cannot plan for birth with any certainty, many of them experience labour and delivery in referral communities as a crisis event fraught with anxiety. The literature suggests that, within a regionalized perinatal system, small maternity services can offer safe care provided that an efficient mechanism for intrapartum transfer has been established. This commentary provides recommendations for sustainable maternity care that will meet the needs of women, their families, and maternity caregivers in rural communities. The recommendations stem from a rural maternity care program of research, consultations with communities, and review of relevant epidemiologic and policy literature.