Rural Maternity Care Research Articles

IN PRAISE AND SEARCH OF MIDWIFERY WELL-SUITED To RURAL WOMEN

In order to investigate rural maternity care from the perspective of women, narrative interviews were conducted with 36 mothers and 36 health care workers in three small community case study sites in south central Ontario in 2000. Based on the resulting data, this article suggests numerous ways that living rurally affects maternal health. It goes on to explore ways in which midwifery is particularly well-suited to addressing the needs of women living in rural places and identifies sites of resistance to rural midwifery. The research findings indicate that a commitment to the sustained provision of rural midwifery services is well worth the effort and investment required, and this article discusses implications of such a commitment for both practitioners and policy makers.

Apple Tree Maternity: A Qualitative Exploration of the Development of a Rural Collaborative Interprofessional Maternity Care Service

Introduction: There is currently a maternity care crisis in Canada, with many of the obstetricians and family physicians reaching retirement age in the next 10 years. Primary midwifery care services may offer solutions. However, due to the many constraints and difficulties faced by midwives practicing in rural settings, there is an emerging interest in exploring interprofessional collaborative models of maternity care as a possible solution to the crisis. This study documents the process and experiences of care providers in establishing and providing collaborative interprofessional maternity care in rural British Columbia. Methods: Semistructured interviews were conducted with key stakeholders (primary care providers and allied health professionals) working at Apple Tree Maternity. Interviewees spoke to both the process of establishing a new collaborative interprofessional model of care and the experience of working and providing care within the model. Findings: Four main themes emerged through the dialogue with the stakeholders: motivation for collaboration; challenges and barriers to collaborative care; attributes and benefits of collaborative care; and core qualities and recommendations for successful interprofessional collaboration. Based on their experience of establishing and working within a new model of collaborative, interprofessional, rural maternity care, the study participants identified core qualities and recommendations for successful interprofessional collaboration in a rural community to be mutual trust and respect; common philosophy of care, mutual commitment, and genuine desire to collaborate; clear and effective communication; ensuring the collaborative model is responsive to the unique needs of specific communities; community support; supportive institutional culture; and alternative payment plans and billing structures. Conclusion and implications for practice: This study revealed a number of attributes to collaboration that mirror those identified by others. In addition, study participants identified particular challenges unique to the rural context. Further research documenting the care provider experiences of interprofessional collaboration in other rural settings is warranted. In addition, there is also a need to explore and document the experiences of collaborative practice, in both rural and urban settings, from the client perspective. It is only when this is achieved that significant policy change suggestions should be made that will facilitate both collaborative practice and an improvement in care to women in rural settings. The need for this research is vital given the maternity care crisis in British Columbia and the need for supporting sustainable rural maternity care models. This article has been peer reviewed.

Navigating geographical disparities: access to obstetric hospitals in maternity care deserts and across the United States

BackgroundAccess to maternity care in the U.S. remains inequitable, impacting over two million women in maternity care “deserts." Living in these areas, exacerbated by hospital closures and workforce shortages, heightens the risks of pregnancy-related complications, particularly in rural regions. This study investigates travel distances and time to obstetric hospitals, emphasizing disparities faced by those in maternity care deserts and rural areas, while also exploring variances across races and ethnicities.MethodsThe research adopted a retrospective secondary data analysis, utilizing the American Hospital Association and Centers for Medicaid and Medicare Provider of Services Files to classify obstetric hospitals. The study population included census tract estimates of birthing individuals sourced from the U.S. Census Bureau's 2017-2021 American Community Survey. Using ArcGIS Pro Network Analyst, drive time and distance calculations to the nearest obstetric hospital were conducted. Furthermore, Hot Spot Analysis was employed to identify areas displaying significant spatial clusters of high and low travel distances.ResultsThe mean travel distance and time to the nearest obstetric facility was 8.3 miles and 14.1 minutes. The mean travel distance for maternity care deserts and rural counties was 28.1 and 17.3 miles, respectively. While birthing people living in rural maternity care deserts had the highest average travel distance overall (33.4 miles), those living in urban maternity care deserts also experienced inequities in travel distance (25.0 miles). States with hotspots indicating significantly higher travel distances included: Montana, North Dakota, South Dakota, and Nebraska. Census tracts where the predominant race is American Indian/Alaska Native (AIAN) had the highest travel distance and time compared to those of all other predominant races/ethnicities.ConclusionsOur study revealed significant disparities in obstetric hospital access, especially affecting birthing individuals in maternity care deserts, rural counties, and communities predominantly composed of AIAN individuals, resulting in extended travel distances and times. To rectify these inequities, sustained investment in the obstetric workforce and implementation of innovative programs are imperative, specifically targeting improved access in maternity care deserts as a priority area within healthcare policy and practice.

Closing the Gap: How a Community Effort Can Improve Rural Maternity Care.

Closing the Gap: How a Community Effort Can Improve Rural Maternity Care.

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia.

In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken. The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers. The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services. The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'. All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals. This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

Descriptive Report of a Pharmacist-Directed Preconception Care Outreach Program in a Rural Maternity Care Desert.

Preconception care is the prevention and management of biomedical, behavioral, and social risk factors to improve pregnancy outcomes and overall health for reproductive-age patients. A community-based pharmacist-directed preconception care outreach program was developed for women ages 18-45 years living in a rural maternity care desert to help them identify potential health risks and provide them with the needed education, counseling, or referrals to address these risks. Supervised student pharmacists, pharmacy practice residents, and pharmacy faculty from a local University collaborated to provide this program at four community events in conjunction with a mobile health clinic. A summative evaluation was performed after the events concluded, modeled after the RE-AIM framework. One hundred and forty-one women were served by the outreach program. Nearly 98% reported at least one preconception health risk, and 45% reported a barrier preventing them from being able to have an appointment with a physician in the last year. The outreach program was feasible to implement and can be adapted to different settings. Pharmacist-directed outreach programs in rural communities may benefit patients who are not receiving or do not have access to such care in traditional healthcare settings.

CNM/CMs Fill the Gap in Rural Maternal Care.

The United States is in the midst of a maternity care crisis. A key driver is workforce shortages, which impacts maternity care service delivery in rural areas significantly. The midwifery model of care remains underutilized. Midwifery care delivered by certified nurse-midwives and certified midwives is heavily endorsed and supported in the extant literature, but no firm national actions have been taken to move recommendations into funding or practice. Certified nurse-midwives and Certified Midwives are able to care for low-risk pregnancies and are uniquely situated to address factors associated with social determinants of health in rural areas. One of the solutions to the rural maternity care crisis is scaling up the midwifery workforce. Individual, institutional, state, and federal factors are discussed.

The Role of the Family Physician in Rural Maternity Care.

Of the 28 million rural women of reproductive age in the United States, ∼7 million of them live in areas of limited access to maternity care. While only 6.7% of Family Physicians currently provide maternity care, they are the only delivering physicians in 27% of rural hospitals. Of the 1.6% of Family Physicians performing cesarean deliveries as a primary surgeon, 57.3% do so in a rural county and 38.6% do so in a county without an obstetrician. Cultivation of the next generation of Family Physicians providing maternity care is essential to prevent further spread of existing maternity care deserts.

How State Perinatal Quality Collaboratives Can Improve Rural Maternity Care.

Perinatal Quality Collaboratives (PQCs) are now present in nearly all states and provide important tools and strategies for improving maternal outcomes. State PQCs can focus their strengths to address rural maternal health challenges using support groups of rural hospitals, of tertiary facilities that network with them, and of other PQCs to share best practices for rural hospitals to: (1) Support networks of care and telehealth; (2) Support remote education and training; (3) Implement rural appropriate versions of National Safety Bundles; (4) Engage and support providers beyond obstetricians; and (5) Engage community members and resources.

P27 - MGP - the answer to sustainable rural maternity services in Victoria. The Journey from a service perspective

For anyone with a knowledge and passion for Midwifery Group Practice (MGP) the answer to a sustainable rural maternity service seems simple. We know that continuity of care improves outcomes for birthing families but for smaller services it can also be the key to sustainability. Existing models of rural maternity care with the dual expectations of nurse/midwives are problematic, by changing the way midwives work to a caseload model of care through the implementation of MGP, rural maternity services are better able to recruit and retain midwives as well as respond to increased consumer demand for continuity of midwifery care. This presentation reflects on the experience of several health services in regional Victoria at different stages of their journey towards sustainable maternity care. These rural units are reinvigorating their maternity services by introducing MGP. This discussion looks at the journey towards MGP from the perspective of multiple services with the hope that sharing learnings will lay a better foundation for others to build on. As part of this discussion we will focus on the journey to change. The importance of collaborative partnerships with higher level services will be highlighted, not only for women with identified risk, but for improved quality, safety and governance. The value of midwives maintaining continued exposure to complex care for midwives working in low volume birthing units will also be discussed along with the industrial challenges that change brings. With the understanding that MGP offers greater sustainability for rural maternity services and the knowledge that continuity of carer is highly desired by women and has better outcomes for all women but particularly for some of the very vulnerable women and families in these disadvantaged rural communities is it time to look at the framework that surrounds the introduction of these models and for greater departmental and industrial support and reform?

Building Blocks to Sustainable Rural Maternity Care: Toward a Systems Approach to Service Planning.

This qualitative study aimed to understand, document and analyze system supports needed to sustain rural maternity care in communities without local access to Caesarean section. In-depth interviews and focus groups with 58 healthcare providers and administrators from rural British Columbia were conducted in 2017/2018. Themes from the data led to the development of five systems interventions necessary to stabilize local maternity care: (1) building nursing confidence; (2) supporting interprofessional teams; (3) efficient transport to referral sites; (4) clear inclusion criteria for local deliveries; and (5) enhanced relationships with referral centres.

Midwives' experiences of reducing maternal morbidity and mortality from postpartum haemorrhage (PPH) in Eastern Nigeria.

BackgroundPostpartum haemorrhage (PPH) is one of the major complications of childbirth which may result in maternal morbidity and mortality, especially in low and middle-income countries like Nigeria. Midwives play a vital role in preventing and managing PPH in Nigerian rural communities. The aim of this study is to understand the experiences of midwives in rural maternity care settings in order to provide appropriate support and improve practice.MethodsAn exploratory, qualitative study of a purposive sample of 15 practicing midwives was carried out using semi-structured interviews from November 2018 to February 2019. Data were transcribed verbatim and analyzed using content analysis.ResultsFour themes were identified: 1. interventions for preventing PPH; 2. approaches to managing PPH; 3. challenges of preventing and managing PPH and 4. ways of supporting midwives to overcome these challenges in rural health care settings. Midwives employed various strategies, such as antenatal education, diagnosis and treatment of anaemia to counteract complications from possible PPH. Understanding PPH as a life-threatening condition enabled the midwives to provide holistic and effective management that sometimes involved a multidisciplinary team approach. Inadequate resources and delay in seeking health care, however, militate against their efforts. The midwives also identified the need for continuing education and training to enhance their standards of care.ConclusionThese midwives in Nigerian rural health care settings engage in preventive practices and active management of PPH though not without barriers, such as inadequate resources. There is a need for midwives in rural areas to have cultural competence, be provided with adequate resources and participate in ongoing education in order to be more effective.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12884-022-04804-x.

Northern Ontario's Obstetrical Services in 2020: A developing rural maternity care desert.

Rural maternity care services matter. Obstetrical care in rural Canada has seen concerning trends of service closures and decreasing numbers of family physicians who predominantly provide this service. Such reductions have been shown to have a serious impact on maternal/foetal well-being. This study investigated the present state of obstetrical services in Northern Ontario, comparing results to those of the last similar survey in 1999. All 40 Northern Ontario communities with hospitals were surveyed, as were the 16 midwife practices in the region. : Of the 35 rural and 5 urban hospitals surveyed, the number not offering obstetrical care has risen from 37.5% in 1999 to 60% in 2020, with all the closures having been rural sites. There have been no re-openings of obstetrics in hospitals that did not offer obstetrics in 1999. Women in the 9 communities that had offered maternity services in 1999, but no longer do in 2020, now travel an average of over 1.5 h to access these services. In those communities that continue obstetrics, but stopped offering caesarean sections, women now travel 2.5 h for this surgery. Although the total number of general physicians remains at the 1999 level, the number offering intrapartum care has dropped by 65% in urban centres and by 49% in rural ones still providing maternity care. Like much of the rural United States, rural Northern Ontario is well on its way to becoming a maternity care desert. As proven in Southern Australia, supportive government policies and programmes should be established and education reform enacted to reverse this concerning trend.

Care providers' experiences with and attitudes towards virtual antenatal care: Findings from a qualitative study in British Columbia.

Virtual care has emerged as an adjunctive response to challenges in rural health care, including maternity care, and use has accelerated during the coronavirus disease 2019 (COVID-19) pandemic. This gives rise to the need for a strategic plan for post-COVID-19 virtual maternity care in rural communities. To date, no provincial initiative has focused on understanding and documenting the needs of maternity care practitioners to provide virtual care. Qualitative study, including virtual interviews and focus groups with rural primary maternity care providers and urban and rural specialists on perceptions of the utility of virtual maternity care pre- and post-COVID-19, and benefits and barriers of virtual care. Data were thematically analysed. In total, 82 health care providers participated in the study. Health care provider responses fell into three categories: Attributes of virtual care, barriers to virtual care and system interventions needed to optimize the provision of virtual perinatal care. Participants expressed a desire for use of virtual communication tools post-COVID-19, continued ability to use fee codes for virtual care and a need for more secure texting options. The benefits of tripartite consultations were noted by many participants; impacts of the transition to virtual care included additional workload and interrupted workflow. Concerns over the lack of physical examinations and challenges in building relationships with patients when providing virtual care were frequently noted. Adapting the current implementation of virtual maternity care in British Columbia may be enhanced through several provider- and evidence-derived strategies, many of which are currently underway in BC. The results from this provincial survey will be used to focus further discussion on the characteristics of an optimal system to meet patient and provider needs within a rural context.

MaterCare International in Mission.

MaterCare International (MCI) is an international group of Catholic obstetricians and gynecologists, which has adopted a preferential option for mothers and babies. MCI's mission is to carry out the work of Evangelium Vitae (the Gospel of Life) by improving the lives and health of mothers and babies, both born and unborn. This is achieved through new initiatives of service, training, research, and advocacy, which are designed to reduce the tragic levels of abortion world-wide, and maternal and perinatal morbidity and mortality in developing countries. This paper describes the history of MCI's formation, how it developed and applied a model of comprehensive rural maternity care for developing countries, and numerous other activities upholding the dignity of life and providing advocacy for women and their children. The future of MCI lies in our answer to the 2001 call of Saint Pope John Paul II to the medical profession to "commit whole-heartedly to the service of human life … promoting the ideal of unambiguous service to the miracle of life!"

The impact of family physicians in rural maternity care.

Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering. Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Providing respectful maternity care in northern Ghana: A mixed-methods study with maternity care providers

ObjectiveThis study explored providers’ perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices. DesignMixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities SettingGovernment health facilities in rural northern Ghana Participants43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care. Measurements and findingsWe calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions. Key conclusionsEven among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present. Implications for practiceFurther research and programmatic efforts are needed to address the gap between knowledge and behavior.

Rural resilience: The role of birth centers in the United States.

PurposeTo explore the role of the birth center model of care in rural health and maternity care delivery in the United States.MethodsAll childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data RegistryTM user sites between 2012 and 2020 are included in this descriptive analysis.FindingsBetween 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data RegistryTM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities.ConclusionsRural populations cared for within the birth center model of care experienced high‐quality outcomes.Health Policy ImplicationsA major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.

Routine Healthcare Utilization Among Reproductive-Age Women Residing in a Rural Maternity Care Desert.

It is important that women of reproductive age have access to and use routine health services to improve birth outcomes. While it is estimated that more than 5 million women in over 1000 counties across the United States live in maternity care deserts, to date there have been no published studies characterizing access and barriers to routine healthcare utilization in these areas. Therefore, a cross-sectional study was conducted in a rural county in northwest Ohio with 315 women ages 18-45years. Health insurance coverage, usual source of care, length of time since routine check-up, and barriers to receipt of health services were assessed via a self-reported, anonymous survey. Over one-tenth (11.3%) of participants reported having no health insurance coverage. A total of 14.4% reported having no usual source of care and 22.8% reported not having a routine check-up in the past year. Just over one-half (53.0%) of participants reported having at least one barrier to accessing health care. In a logistic regression analysis, having a routine check-up in the past year was inversely associated with number of barriers (OR 0.73, 95% CI 0.56-0.95; p = 0.019); women who reported more barriers were less likely to report receipt of preventive care in the past year. The results of this study reveal that many reproductive-age women living in a maternity care desert face challenges in accessing health services. Policies and programs need to be developed and implemented to close these gaps and maximize opportunities for optimal health.

Rural healthcare delivery: Navigating a complex ecosystem.

Clinical Practice Guidelines (CPGs) provide evidence-based recommendations for Healthcare Providers (HCPs) to utilize when making patient care decisions. Rural providers face challenges in the provision of evidence-based care, including the use of guidelines. The aim of this article is to explore the complexities of providing healthcare in rural areas. This article will focus on a specific aspect of rural maternity care with well-established CPGs, the prevention of Rhesus D factor alloimmunization. An applied health research approach, interpretive description, utilized semistructured interviews with HCPs across the vast geographic region of northern British Columbia. The study found that HCPs are aware of guidelines but face various barriers during implementation. In order to implement guidelines within practice, rural HCPs adapt processes to overcome local barriers. These process adaptations need to be identified and shared across a large health authority with a complex geography and healthcare system to ensure quality of care.