The Applied Policy Research Unit (APRU) has released its latest report entitled, “The Safety of Rural Maternity Services Without Local Access to C-Section.” This major realist review is the third in a series of reviews on maternity services for rural and remote women here in BC and around the world.
This work offers a uniquely comprehensive examination of evidence on what has been a policy and planning problem for several decades all over the world. For the first time, institutional data, population health evidence, case studies, qualitative studies and thoughtful analysis have been considered across fields of research that historically have been siloed: persistent rural health disadvantages; the psycho-social risk to women of not having local services; the clinical dangers of greater distance to services found in every jurisdiction around the world; the high-quality outcomes of existing or historical primary services led by both physicians and midwives; the challenges and importance of service sustainability; and even the relationship of volume to outcomes for maternity.
“For rural women and their families, the pressing question is not whether a given birthing unit, model or tier of service is safer, but whether that potential improvement in safety out-weighs the increased risk of traveling to care.”
Reviewing evidence from Canada, Australia, the United States, New Zealand, Norway, Sweden, Finland, Denmark, Wales, Scotland, England, France, Germany, Iceland, the Netherlands and more, the findings are clear. With active risk screening, regionalized referral and functioning emergency transport, local primary maternity services are much more safe for rural women than having to travel to higher-resourced units outside their community.
Context: Services must be planned to meet the Institute of Health Improvements’ Triple Aim goals of:
- (a.) Improving the health of populations;
- (b.) Improving the patient experience of care (including quality and satisfaction), to which B.C. has recognized the additional requirement of improving the experience of delivering care for providers and support staff as critical to patient-centred care built on efforts of those who deliver and support health services; and
- (c.) Reducing the per capita cost of health by focusing on quality (especially effectiveness and appropriateness) and the efficiency of health care delivery.
Consideration of the safety of primary maternity services must take place within recognition of an expansive definition of safety to include cultural, social and personal safety in addition to physiological safety. Additionally, clear lines of responsibility for rural maternity care must be established in the Ministry of Health, Health Authorities and Perinatal Services BC to ensure consideration, uptake and evaluation of the following recommendations.
From this vantage point, the following criteria must be met to support primary maternity services:
I. Planning Issues
- Maternity services for rural and remote communities must be systematically planned based on the need for services of the population catchment;
- Special consideration needs to be given to meeting the maternity service needs of remote aboriginal populations;
- Rural primary maternity services need to be supported as a stated priority for health planners;
- Services must be positioned within a regional networked model of maternity care, which assumes clear referral lines for triage to higher levels of care when necessary;
- Guidelines for identification of candidates for birth in a low resource environment (those likely to have an uncomplicated vaginal delivery) need to be refined and adopted across the rural and remote environment;
- Effective and efficient perinatal transport systems must be in place for instances when emergency transport is necessary;
- A quality management framework for rural community services needs to be established and led by rural maternity providers, and
- A decision aid for facilitating decision on place of birth at a patient level must be developed representing the patient priorities alongside relevant clinical data.
II. Provider Issues:
- Individuals providing rural maternity services must be well-qualified and work within a Continuous Quality Assurance monitoring framework with adequate opportunities for Continuing Medical Education;
- Innovative models of midwifery services for rural communities with planned primary maternity services and absence of current maternity services need to be supported;
- Barriers to interprofessional practice between midwives and generalist physicians in rural and remote communities need to be identified and addressed;
- Primary maternity services must take place within the context of a well-functioning interdisciplinary local team including care providers, allied health providers and local administrators.
- Population catchment outcomes need to be prospectively monitored and feedback needs to be given in a timely and flexible way to individual communities, service strata, and regions;
- Service utilization patterns as well as referral patterns at the population catchment level are an important indicator of the quality of service and need to be part of the ongoing monitoring;
- CME/CPD should be provided inter-professionally, on site, and linked to outcome monitoring and driven by the needs of the local maternity care team.