Women's needs in maternity care and related sustainable service models in rural areas: a comprehensive systematic review of qualitative evidence.

Abstract

Review question/objective The objective of this review is to synthesise the best available evidence on the experiences of women's needs in maternity care and existing sustainable service models in rural areas. Specifically, the review questions are: What are maternity care needs for women in rural areas? What are existing models of sustainable services in maternity care in rural areas? Background Childbirth is one of the most important and memorable events in a woman's life. Maternity care refers to care that women receive during pregnancy through to early postnatal period. Research has found that many years later, women's memories in childbirth are still accurate and strikingly vivid about maternity care that they experienced. 1, 2 However, when women's needs in maternity care are not met, women can have less positive birth experience as they encounter stress, fear, anxiety and many difficulties.3, 4 In the last few decades, rural communities in developed countries such as England5, Canada6 and Australia7 have experienced the closure of obstetric services, forcing thousands of pregnant women to travel for a long distance to a centralised unit to access maternal care.7 The decision to close small maternity units was due to the shortage of health care professionals, safety and quality considerations and the cost consideration.7, 8 The difficulty of recruiting and retaining health providers who are willing to provide obstetric care in rural areas diminishes anaesthesia and caesarean section capabilities. The absence of these capabilities in rural communities raises the concerns on the safety and quality of birthing services.9 However, some researchers suggest that the closure of local rural maternity care services can cause poor birth outcomes for women and infants.10, 11 Some investigations have hypothesised that low-intervention styles of maternity care offered in small rural settings are optimal for uncomplicated deliveries.12, 13 In terms of cost consideration, health authorities and health departments may anticipate savings through closing rural maternity units. However, the Rural Doctors Association of Australia7 argues that this is not cost-effective because of a number of reasons. Firstly, delivery costs are usually lower in smaller hospitals. Secondly, closure shifts costs from the health budget to rural families and communities in the form of transport, accommodation, loss of income due to absence from a farm or other employment and spending diverted from local businesses. Thirdly, closure affects the sustainability of the community. In addition, the larger hospitals where mothers are forced to travel to give birth incur increased costs, often without commensurate increases in human or financial resources. Finally, ambulance services face higher costs, workloads and responsibilities, frequently without the increased funds, staff or training needed to cover them. As Klein et al.11 emphasise that ‘cost savings may prove elusive because the decision to close hospitals in smaller communities carries with it health and economic risks’ (p. 120). The loss of maternity services in rural areas negatively affects not only childbirth experience, the well-being of mothers and their babies but also the sustainability of rural communities. Research has demonstrated various adverse effects associated with travel for rural parturient women including stress, financial loss, separation from spouse, children and community, and lack of continuity of care. 3, 4, 14 Furthermore, the closure of maternity services has been linked with adverse outcomes for mothers and babies. In particular, rural parturient women who had to travel for care had a greater proportion of complicated deliveries, higher rates of prematurity, higher costs of neonatal care15 and were more likely to undergo induction of labour16 than women who did not have to travel. It is suggested that these negative outcomes may be a consequence of the increased stress-physiological and psychological associated with travel and parturition in unfamiliar settings which interfere with the normal process of labour. Finally the absence of obstetric services in rural areas affects the sustainability of rural communities.11 As health professionals stop providing maternity care, women from less central communities must travel to a distant centre to get that care. On the other hand, it is impossible for midwives to provide care in such communities because midwives need physician and institutional back-up to practise. Health care providers and the community suffer the loss of skills related to reproductive and women's health due to the absence of maternity services. Existing residents of the community may try to move because of the lack of health care services. In addition, the local hospital is an important employer, sometimes the largest employer, in a small community. Its downgrading or closure has a significant impact on the socio-economic vitality of the community.7 Therefore, the community itself becomes dysfunctional and unstable as Klein and colleagues 11 recognised that maternity and newborn care are lynchpins for sustainable communities medically, socially and economically. Qualitative research on women's needs in maternity care and sustainable model of care in rural areas has aimed to improve access and outcomes for women and babies. In spite of being different in definitions of rurality, most of them categorise location in terms of distance from cities and population sparsity. For instance, Statistics Canada defines “rural areas” as all areas outside urban areas with a population of less than 1,000 people and a population density of less than 400 people per square kilometre.17 The United States Census Bureau identifies two types of urban areas (Urbanized Areas (UAs) of 50,000 or more people; and Urban Clusters (UCs) of at least 2,500 and less than 50,000 people) and defines ‘rural’ as those areas outside of the urban areas.18 Thus, it is expected that rural definitions are presented and clarified in each study. The review will only include studies in developed countries as these countries have experienced the same issues in rural areas e.g. shortages of health workforce, closure of small maternity units and have comparable health care system. Focusing on research conducted in these countries will help synthesise the needs of women and sustainable models of care in rural areas. In dealing with the issues discussed above, those countries have developed maternity service models in rural areas such as midwifery-led care, collaborative model of care and planned homebirth model of care. However, are these models meeting the needs of women in maternal care? By reviewing the literature systematically, the project will provide an evidence-based answer to this question. We have searched JBI library, Cochrane Library and Medline and found no other qualitative systematic reviews on this topic. Inclusion criteria Women who have child birth experience(s) in rural areas in developed countries such as Australia, England, USA, Canada, New Zealand and others. Since research on these topics aims to improve access and outcomes for women in rural areas, all women regardless of being classified as low risk or high risk should be included. Maternity services in rural areas should provide care for all women regardless of their health conditions. There is no any other restriction. Phenomena of interest The phenomena of interest are women's experiences of maternity care in a rural setting. The review will focus on the whole period of maternal care including antenatal care, birthing and early postnatal care. Types of studies The review will consider qualitative study designs including ethnography, grounded theory, action research, case studies. This review will also consider non-research textual evidence such as text and expert opinion. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. Other databases available at University of Tasmania to be searched include: PubMed, Cross search, Summon search, Mednar, ProQuest, Proquest theses and dissertations-Health and Society, HealthInsite. The search for unpublished studies will include: Digital theses, ePrint repository. A second search using all identified keywords and index terms will then be undertaken across all included databases. Obstetric services in rural areas in some developed countries such as Canada, England and Australia have changed in the last two decades. Many small rural maternity units in these countries have been closed due to the shortages of health professionals, safety and cost consideration. In Australia, since 1996 more than a half of small maternity units have been closed. Therefore publications in the past 20 years will be searched using the following key words: maternity experience, maternity needs, rural areas, models of care, continuity of care, access to maternity care, childbirth location, maternity choices, workforce shortages, rural isolation, rural communities, and sustainable maternity models of care. Thirdly, the reference list of all identified reports and articles will be scanned and searched for additional studies. Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from JBI-QARI (Appendix I). Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from JBI-NOTARI (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative papers will, where possible be pooled using the Narrative, Opinion and Text Assessment and Review Instrument. (JBI- NOTARI). Textual papers will, where possible be pooled using the Narrative, Opinion and Text Assessment and Review Instrument. (JBI- NOTARI). This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling the conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Conflicts of interest There is no conflict of interest in this review paper.