Rural Maternity Services Research Articles

Sustainability of rural Victorian maternity services: ‘We can work together’

BackgroundRural maternity service closures and service level reductions are continually increasing across Victoria. There is limited understanding of how rural board members and executives make decisions about their maternity service’s operations and sustainability. AimTo examine perspectives of rural Victorian board members and executives on the sustainability of rural maternity services. MethodsThis was a qualitative study. Interviews were conducted via Zoom™ with 16 rural Victorian hospital board members and executives. Data were thematically analysed. FindingsSevere shortages in the rural maternity workforce, primarily midwives, have contributed to service sustainability decisions. Challenges in offering midwifery workforce incentives cause difficulty in overcoming workforce shortages. A rural maternity workforce strategy harnessing connection with regional services was called for. Innovative models of maternity care were often actioned at the point of service suspension or closure. Participants requested a government policy position and funding for innovative, safe, and sustainable models of care in rural settings. DiscussionThere is an opportunity for workforce planning to occur between regional and rural services to ensure the development of sustainable maternity models such as midwifery group practice and incentivise the workforce to address current deficits and sustain service provision. ConclusionModels of care developed with rural communities, in collaboration with regional services, have the potential to strengthen the delivery of safe, sustainable maternity services. Workforce modelling and centralised government policies aimed at arresting workforce deficits are suggested to provide rural health service leaders with strategic and operational directions to support the delivery of safe, sustainable maternity services.

System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program

BackgroundThe Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four “pillars”: increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology.MethodsWe conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings.FindingsParticipants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models.ConclusionRural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

Rural maternity and media discourse analysis: Framing new narratives.

Continued rural maternity closure across Australia has seen impacts on women and families such as financial pressures, quality and safety concerns, and emotional pressure. This review aimed at understanding how media coverage of rural maternity and closure are presented and what impact this may have on maternity service sustainability. This research seeks to examine media discourse and characteristics of online newspaper articles related to rural maternity services. A narrative review was conducted using thematic discourse analysis to examine online newspaper content published in Victoria, Australia from 2010 to June 2021. Local maternity services were a source of community interest for rural people. Coverage of negative outcomes for mothers and babies was highlighted by rural newspapers; however, increased content over the last 12-month period focused on community support for the sustainability of rural maternity services. Recent community support in newspaper articles coincided with maternity services reviews and retaining some of these rural services. Community support in media may provide a protective social pressure, leading rural health services to consider this when reviewing the sustainability or closure of rural maternity services. Media attention about sustaining local maternity services by highlighting issues and representing community voices may influence health executive to consider opportunities to remodel and sustain high-quality and safe maternity care in rural settings. Knowing how rural health executives consider media, community pressure, and how it impacts expediency of maternity service closure decisions is unknown and an important gap in knowledge to explore and understand.

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?

O9 - Keeping Rural Maternity Services a top priority: a case review of transitioning to a midwifery-led model of care

Midwifery-led Continuity of Care (MCoC) models is the gold standard in maternity care. This presentation will outline how a regional district health service in NSW implemented its first MCoC model, ensuring a small rural maternity service did not close. Evaluation of the model proved it is safe, cost-effective and highly valued by women. Case review of a district health service co-design and implementation journey that achieved access to a MCoC model in a regional context. The small rural maternity service previously supported on average 40 women a year to birth under a GP led model. The service was proving unsustainable and at risk of closure. With executive support, a MCoC model was co-designed and implemented in partnership with community, midwifery and obstetric teams. Commencing in 2020, the model successfully commenced whilst enduring the impacts of simultaneously moving to a new hospital build and managing a pandemic response. The implementation of the MCoC model enabled access to care for all women, including those with risk during pregnancy by bringing specialist obstetric care to the local community. This is of particular importance in the region to ensure access to safe care for all women and their families close to home in rural and reginal settings. Compared with the previous service, women who received care from the MCoC model in 2021 had improved outcomes, including higher rate of spontaneous labour, more likely to have a normal birth, a reduced rate of caesarean section, required less medical pain relief and were more likely to breastfeed. Access to the MCoC increased the likelihood of women to access pregnancy care early and ongoing.

Evaluating the impact of a maternity and neonatal emergencies education programme in Australian regional and rural health services on clinician knowledge and confidence: a pre-test post-test study

IntroductionAlmost 78 000 women gave birth in the state of Victoria, Australia, in 2019. While most births occurred in metropolitan Melbourne and large regional centres, a significant proportion of women...

Rural Australian Doctors’ Views About Midwifery and Midwifery Models of Care: A Qualitative Study

BACKGROUND AND PURPOSEAustralian rural areas access to midwifery continuity of carer models is restricted. Lack of medical support has been identified as one of the reasons midwifery continuity of carer models have not been implemented. The purpose of his study was to explore rural Australian doctors’ views about midwifery and midwifery continuity of carer models.STUDY DESIGNA qualitative study with general practitioner and specialist obstetricians (n = 10) working in Australian rural maternity services. Semi-structured interviews were undertaken and analyzed using thematic analysis.FINDINGSParticipants’ views of midwifery and midwifery continuity of carer models were expressed in three themes. The themes related to the concepts of knowing: knowing the model, knowing the midwife, and knowing the system. Participants had misconceptions and misunderstandings of the model, midwifery, and systems issues relating to midwifery continuity of carer models.CONCLUSIONIncreasing understanding about midwifery and midwifery continuity of carer models may facilitate implementation of these models. A national education program for doctors about the structure and function of midwifery continuity of carer models would support knowledge building for obstetric doctors. Strong leadership and incentivization for health services may be needed to sustainably roll-out rural models. At a service level, responsibility for establishing and sustaining models should shift from local midwife leaders to hospital executives.

General practitioner obstetricians' models of care in rural Western Australia.

BackgroundIn Australia, a significant proportion of women live rurally and deliver their babies in services supported by general practitioner obstetricians (GPOs). While GPOs are known to be an important backbone in the provision of maternity care in Australia, little attention has been paid to their models of care.AimsTo describe the models of maternity care provided by GPOs across Western Australia.Materials and MethodsThis was a multi‐phase mixed‐methods cross‐sectional exploratory study. We invited rural GPOs in Western Australia to complete an online survey about their models of care and a sub‐group of GPOs agreed to an interview to further explore their responses.ResultsThirty‐five GPOs completed the survey and 12 completed an interview. We found that GPOs work in a variety of models, dependent on local community needs, resources and geography. Key attributes of GPO models are continuity of care, safety, generalism, accessibility and affordability. GPO care involves continuity of care beyond the time limits of pregnancy.ConclusionsGPOs’ models of care make up an essential part of rural maternity services and have evolved to meet the needs of the communities they serve. This work informs rural generalist trainees of career pathways and policymakers about rural service provision.

Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia

BackgroundThe sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change.MethodsA descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant’s commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey.ResultsOverall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12–60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, “People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements “People who work here are determined to implement this change”, “People who work here want to implement this change”, and “People who work here are committed to implementing this change.ConclusionResults of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

Orthodox and unorthodox practices by traditional birth attendants in Nsukka area of Enugu State, Southeast Nigeria

Unskilled Traditional Birth Attendants (TBA) is prevalent in rural Nigeria due to communal culture and traditions, their compassionate attitude, and non-availability of appropriate health facilities within the communities. Yet, there is no clear framework defining their roles, locations and practices. This study aimed to identify the pattern and practices of TBA in Nsukka area of Enugu State, and evaluate their roles in rural maternity services in Enugu state of Nigeria. This was a mixed method cross sectional study involving a questionnaire-based survey and Focus group discussions (FGD). Seventy-eight TBAs, were recruited for this study. Structured interviewer-administered questionnaire was used to collect quantitative data and a semi-structured discussion guide was used for the FGD – one FGD for each development center. SPSS version 25 was used for statistical analysis. Records of FGD sessions were transcribed, condensed into themes, and analyzed. A total of 78 TBAs were interviewed, 26 from each of the three development areas. Majority (66.0%) completed primary education while 9.0% did not have any formal education. Almost two-third (65.4%) uses exclusively traditional methods in their practice, whereas 34.5% combined orthodox method. Three focused group discussions showed almost all the TBAs in the study could neither identify different complications and when to refer nor signs separating different stages of labour. Poorly educated TBA in the Nsukka area of Enugu State combines orthodox medicine with herbs and traditional healing methods. Their appreciation and management of danger pregnancy signs and referral system are lacking. Key words: Traditional birth attendants, healthcare, Nsukka, informal health, Labor.

Rural midwifery practice in Aotearoa/New Zealand: Strengths, vulnerabilities, opportunities and challenges

Background: The sustainability of rural maternity services is threatened by underfunding, insufficient resourcing and challenges with recruitment and retention of midwives. Aims: The broader aim of this study was to gain knowledge to inform the optimisation of equitable and sustainable maternity care for rural communities within New Zealand and Scotland, through eliciting the views of rural midwives about their working conditions and practice. This article focuses on the New Zealand midwives’ responses. Method: Invitations to participate in an online questionnaire were sent out to midwives working in rural areas. Subsequently, themes from the survey results were followed up for more in-depth discussion in confidential, online group forums. 145 New Zealand midwives responded to the survey and 12 took part in the forums. Findings: The New Zealand rural midwives who participated in this study outlined that they are attracted to, and sustained in, rural practice by their sense of connectedness to the countryside and rural communities, and that they need to be uniquely skilled for rural practice. Rural midwives, and the women they provide care to, frequently experience long travel times and distances which are economically costly. Adverse weather conditions, occasional lack of cell phone coverage and variable access to emergency transport are other factors that need to be taken into account in rural midwifery practice. Additionally, many participants noted challenges at the rural/urban interface in relation to referral or transfer of care of a woman and/or a baby. Strategies identified that support rural midwives in New Zealand include: locum and mentoring services, networking with other health professionals, support from social services and community service providers, developing supportive relationships with other rural midwives and providing rural placements for student midwives. Conclusion: Midwives face economic, topographic, meteorological and workforce challenges in providing a service for rural women. However, midwives draw strength through their respect of the women, and the support of their midwifery colleagues and other health professionals in their community.

Prevalence and outcomes of overweight and obesity among pregnant women in rural Queensland.

To assess the prevalence of overweight and obese women in the antenatal and perinatal periods, in rural hospitals; and to evaluate neonatal and maternal outcomes, including transfer to larger birthing centres. A retrospective clinical chart audit. Rural maternity services in five Queensland rural hospitals. Data were collected from 250 women presenting to participating rural hospitals, with an estimated due date in 2016. Obstetric and neonatal data, whether transfer occurred, mode of delivery and any complications, and neonatal outcomes including birth weight and complications were collected. Demographic information collected included maternal age, gravidity and parity, race, smoking status and pre-pregnancy body mass index. The main outcome measures of interest were birth weight, Caesarean rate, transfer rate and diagnosis of gestational diabetes in relation to the body mass index. Over 50% of women were overweight or obese while entering pregnancy, with 5.2% of mothers in the morbidly obese category. There was an increase in the birth weight of mothers with a body mass index of more than 25. The increasing body mass index was associated with an increased likelihood of transfer, diagnosis of gestational diabetes, elective and, especially, emergency Caesareans performed at the hospital. Twenty-four percent of women continued to smoke throughout pregnancy. A high prevalence of obesity was found in the rural obstetric population. As the body mass index increases, so too does birth weight, gestational diabetes, transfer rate and Caesarean section rate. The rates of smoking throughout pregnancy were higher than the average metropolitan rates. These findings have implications not just for rural hospital operation and resources, but also for preventive health activities in rural communities.

Maternity services for rural and remote Australia: barriers to operationalising national policy

IntroductionIn Australia, many small birthing units have closed in recent years, correlating with adverse outcomes including a rise in the number of babies born before arrival to hospital. Concurrently, a raft of national policy and planning documents promote continued provision of rural and remote maternity services, articulating a strategic intent for services to provide responsive, woman-centred care as close as possible to a woman’s home. The aims of this paper are to contribute to an explanation of why this strategic intent is not realised, and to investigate the utility of an evidence based planning tool (the Toolkit) to assist with planning services to realise this intent. MethodsInterviews, focus groups and a group information session were conducted involving 141 participants in four Australian jurisdictions. Field notes and reports were thematically analysed. ResultsWe identified barriers that helped explain the gap between strategic intent and services on the ground. These were absence of informed leadership; lack of knowledge of contemporary models of care and inadequate clinical governance; poor workforce planning and use of resources; fallacious perceptions of risk; and a dearth of community consultation. In this context, the implementation of policy is problematic without tools or guidance. ConclusionsBarriers to operationalising strategic intent in planning maternity services may be alleviated by using evidence based planning tools such as the Toolkit.

The development of a caseload midwifery service in rural Australia.

The past two decades have seen progressive decline in the number of rural birthing services across Australia. Despite health system pressures on small birthing units to close there have been examples of resistance and survival. This descriptive study explored the evolution of a rural birthing service in a small town to offer insight into the process of transition which may be helpful to other small healthcare services in rural Australia. Quantitative data derived from birth registers on number and types of birth from 1993-2011 were analysed. Interviews were conducted between January and August 2012 with nine participants (GP obstetricians, midwives, a health service manager and a consumer representative). This rural maternity service developed gradually from a GP obstetrician-led service to a collaborative care team approach with midwifery leadership. This development was in response to a changing rural medical workforce, midwifery capacity and the needs and wants of women in the local community. Four major themes were developed from interview data: (1) development of the service (2) drivers of change (3) outcomes and (4) collaborative care and inter-professional practice. The success of this transition was reported to rest on strategic planning and implementation and respectful inter-professional practice and alignment of birth philosophy across the team. This team created a unified, progressive community-focused birthing service. The development of collaborative care models that embrace and build on established inter-professional relationships can maximise existing rural workforce potential and create a sustainable rural service into the future.

Building Rural Surgical Networks: An Evidence-Based Approach to Service Delivery and Evaluation

Formalized rural health service delivery networks are emerging as an over-arching response to the attrition of rural surgical and maternity services in Canada. In effective networks, there is strong collaborative leadership, form follows function, core network elements are identified and site-specific variations are accommodated to meet the surgical needs of the population in each geographic catchment. The network catchment must reflect the natural alliances that already exist among health professionals, policy makers, health administrators, academic institutions and communities. Although each key stakeholder plays a key role in determining success, value is added through the synergistic interplay of all participants.

Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety.

BackgroundThe precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. There is emerging international evidence that General Practitioners with Enhanced Surgical Skills (GPESS) are a well-positioned health service solution due to their generalist nature in low-volume settings. A realist review was undertaken to evaluate international evidence on efficacious models of perinatal surgical care. This article presents findings of the safety of such practice, one discrete part of the full realist review.MethodsThis paper was derived from a larger review, which used a realist review methodology to guide the approach, and adhered to the RAMESES quality standard for realist reviews. Seven academic databases were searched in December 2013, using year (1990) and language (English) limiters in keeping with a rapid review approach. Mining of bibliographies in addition to consultation with international experts led to further inclusion of academic and grey literature up to March 2014.ResultsTwo hundred fifty-four articles were originally identified; 119 articles were removed from consideration for lack of fit, resulting in the review of 191 articles from the peer reviewed and grey literature. Of these, 53 pertained to safety and are considered herein. Evidence on the safety of GPESS was consistent in the literature cited. Clinical, case study, and qualitative evidence demonstrates that perinatal surgical care is equally safe when provided by GPESS and specialist physicians.ConclusionFindings allow health planners to confidently build perinatal surgical services around the contribution of GPs with enhanced surgical skills and focus on educational, regulatory, and continuing professional development mechanisms to ensure their sustainability. Volume-to-outcomes associations are variable and inconclusive with regards to safety, suggesting the need for more evidence. These findings, and the attendant health services planning directions, are reassuring as they suggest the viability of local models of care where feasible.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1629-6) contains supplementary material, which is available to authorized users.

Local birthing services for rural women: Adaptation of a rural New South Wales maternity service.

ObjectiveTo describe the outcomes of a public hospital maternity unit in rural New South Wales (NSW) following the adaptation of the service from an obstetrician and general practitioner‐obstetrician (GPO)‐led birthing service to a low‐risk midwifery group practice (MGP) model of care with a planned caesarean section service (PCS).DesignA retrospective descriptive study using quantitative methodology.SettingMaternity unit in a small public hospital in rural New South Wales, Australia.ParticipantsData were extracted from the ward‐based birth register for 1172 births at the service between July 2007 and June 2012.Main outcome measuresBirth numbers, maternal characteristics, labour, birthing and neonatal outcomes.ResultsThere were 750 births over 29 months in GPO and 277 and 145 births over 31 months in MGP and PCS, respectively, totalling 422 births following the change in model of care. The GPO had 553 (73.7%) vaginal births and 197 (26.3%) caesarean section (CS) births (139 planned and 58 unplanned). There were almost universal normal vaginal births in MGP (>99% or 276). For normal vaginal births, more women in MGP had no analgesia (45.3% versus 25.1%) or non‐invasive analgesia (47.9% versus 38.6%) and episiotomy was less common in MGP than GPO (1.9% versus 3.4%). Neonatal outcomes were similar for both groups with no difference between Apgar scores at 5 min, neonatal resuscitations or transfer to high‐level special care nurseries.ConclusionThis study demonstrates how a rural maternity service maintained quality care outcomes for low‐risk women following the adaptation from a GPO to an MGP service.

Reconceptualising risk: Perceptions of risk in rural and remote maternity service planning

Objectiveto explore perceptions and examples of risk related to pregnancy and childbirth in rural and remote Australia and how these influence the planning of maternity services. Designdata collection in this qualitative component of a mixed methods study included 88 semi-structured individual and group interviews (n=102), three focus groups (n=22) and one group information session (n=17). Researchers identified two categories of risk for exploration: health services risk (including clinical and corporate risks) and social risk (including cultural, emotional and financial risks). Data were aggregated and thematically analysed to identify perceptions and examples of risk related to each category. Settingfieldwork was conducted in four jurisdictions at nine sites in rural (n=3) and remote (n=6) Australia. Participants117 health service employees and 24 consumers. Measurements and findingsexamples and perceptions relating to each category of risk were identified from the data. Most medical practitioners and health service managers perceived clinical risks related to rural birthing services without access to caesarean section. Consumer participants were more likely to emphasise social risks arising from a lack of local birthing services. Key conclusionsour analysis demonstrated that the closure of services adds social risk, which exacerbates clinical risk. Analysis also highlighted that perceptions of clinical risk are privileged over social risk in decisions about rural and remote maternity service planning. Implications for practicea comprehensive analysis of risk that identifies how social and other forms of risk contribute to adverse clinical outcomes would benefit rural and remote people and their health services. Formal risk analyses should consider the risks associated with failure to provide birthing services in rural and remote communities as well as the risks of maintaining services.

The closure of rural and remote maternity services: Where are the midwives?

Decisions to close small maternity units in rural and remote communities have often precipitated a community response as women and families rally to save local services. But where are the midwives? We argue here that professional bodies such as colleges of midwives have a responsibility to advocate more strongly at a political level for evidence-based decisionmaking regarding the allocation of rural services.We suggest that adopting a comprehensive definition of maternity services risk that considers both social and health services risks and their impact on clinical risk, could provide a solid basis for effective advocacy by professional bodies.

Rural women's perspectives of maternity services in the Midland Region of New Zealand.

INTRODUCTION Rural women face many challenges with regards to maternity services. Many rural primary birthing facilities in New Zealand have closed. The Lead Maternity Carer (LMC) model of maternity care, introduced in 1990, has moved provision of rural maternity care from doctors to independent midwifery services. Shortages of rural midwives in the Midland region led to rural maternity care being seen as a vulnerable service. AIM To understand the views and experiences of rural women concerning maternity care, to inform the future design and provision of rural maternity services. METHODS Participants were drawn from areas purposively selected to represent the five District Health Boards comprising the Midland health region. A demographic questionnaire, focus groups and individual interviews explored rural women's perspectives of antenatal care provision. These were analysed thematically. RESULTS Sixty-two women were recruited. Key themes emerging from focus groups and interviews included: access to services, the importance of safety and quality of care, the need for appropriate information at different stages, and the role of partners, family and friends in the birthing journey. While most women were happy with access to services, quality of care, provision of information, and the role of family in their care, for some women, this experience could be enhanced. CONCLUSION Midwives are the frontline service for women seeking antenatal services. Support for rural midwives and for local birthing units is needed to ensure rural women receive services equal to that of their urban counterparts.