Rural Northern Research Articles

Barriers and Facilitators to Community Acceptability of Integrating Point-of-Care Testing to Screen for Sickle Cell Disease in Children in Primary Healthcare Settings in Rural Northern Ghana

Introduction: Sickle cell disease (SCD) remains a public health problem especially in sub-Saharan Africa including Ghana. While pilot initiatives in Africa have demonstrated that neonatal screening coupled with early intervention reduces SCD-related morbidity and mortality, only 50-70% of screen-positive babies have been successfully retrieved to benefit from these interventions. Further, systematic newborn screening for SCD as public health programs is lacking. To address this problem, innovation is needed to bridge the diagnostic gap and develop sustainable care programs through universal health coverage. Point-of-care testing (POCT) with high specificity and sensitivity for SCD screening can be more easily integrated into existing immunization programs in Africa and are more likely to improve retrieval rates. This study explored community perceptions and acceptability of integrating POCT to screen for SCD in newborns and children under 5 years of age in primary healthcare facilities in rural Kassena-Nankana Districts of Northern Ghana. Method: This was an exploratory study using qualitative research approach where 10 focus group discussions and 20 in-depth interviews were conducted with community members and health workers between April and June 2022 covering major thematic areas such as community awareness and perceptions of SCD, their views on integrating POCT to screen for SCD, and barriers and facilitators of community acceptability and uptake of SCD screening in children under 5 years of age in primary care settings. The theoretical framework on acceptability of healthcare interventions validated by Sekhon et al. was adopted and used in this study. The interviews were recorded with participants’ consent and transcribed verbatim after repeatedly listening to the recordings. Data was coded into themes using Nvivo 12 software before thematic analysis. The study was approved by the Institutional Review Board of the Navrongo Health Research Centre. Results: Most participants (70.9 %) described SCD as serious and potentially life-threatening condition affecting children. Of 148 community members and health workers, 141 (95.2%) expressed positive views about the screening exercise, which could facilitate diagnosis of SCD in children for early management. However, discrimination, fear of being tested positive, stigmatization, negative health worker attitude linked with issues of maintaining confidentiality were reported by majority of participants as key factors that could negatively impact uptake of the screening exercise. Most participants suggested that health education (74.3 %), short duration of screening processes (74.3%), positive attitude of health workers (69.5%), and screening health workers not being biased (58.8%) as factors that could promote community acceptability. Conclusion: A large majority (over 95%) of participants viewed screening of SCD in children as very important. However, views expressed by most participants suggest that health education, short duration of the screening process, and professionalism of health workers in keeping patients’ information confidential could improve community acceptability. These findings have informed the implementation design for using POCT to screen for SCD in children under 5 years of age in primary care settings in rural Northern Ghana.

Rites of Passage to Patriarchy: Adolescent Boys’ Narratives of Sexuality and Fertility in Rural Northern KwaZulu-Natal

This article reports on a qualitative study that sought to examine understandings of sexuality and fertility among 18–19-year-old adolescent boys in rural northern KwaZulu-Natal. Adolescent boys’ constructions of sexuality and fertility in this study reflect a complex fusion of sociocultural processes, religion and unequal gender norms. How young men understand these factors tends to encourage risky sexual behaviour, and often leads to pregnancies among adolescent girls. In-depth individual interviews and a focus group discussion were conducted with six adolescent boys attending primary healthcare clinics in northern KwaZulu-Natal. Central to the adolescent boys’ discourses about sexuality and fertility was the desire to achieve the status of manhood. The findings suggest that adolescent boys were “inducted” into manhood as they learnt to wield gendered power in heterosexual relationships. In assuming patriarchal power and attaining the status of manhood, adolescent boys objectified girls and reduced them to unequal sexual partners whose role is to bear them children.

Barriers and Facilitators to Successful Intensive Adherence Counseling in Rural Northern Uganda: An Exploratory Interview with HIV-Positive Clients Using the COM-B Framework.

Intensive adherence counseling (IAC) was introduced as a strategy to enhance adherence to antiretroviral therapy (ART) among HIV clients with non-suppressed viral loads. There has been sub-optimal viral load suppression among HIV clients in Uganda enrolled in IAC. However, there is a scarcity of literature on the barriers and facilitators of successful IAC. We aim to explore the barriers and facilitators to successful IAC among HIV-positive clients seeking care in public health facilities in rural northern Uganda. This was an exploratory qualitative study conducted among 15 purposively sampled HIV-positive clients enrolled in IAC in public health facilities offering ART services in northern Uganda. We conducted in-depth interviews using semi-structured interview guides based on the capability, opportunity, motivation, and behavior (COM-B) framework for behaviour change. Data were analyzed using the deductive thematic approach of Braun and Clarke following the COM-B framework. The majority of the participants were females (60%), married (53%), and attained primary education (47%). Barriers to successful IAC were Capability - alcoholism and promiscuity, Opportunity - stigma and discrimination, delayed viral load result, shortage of food, and heavy workload; and Motivation - deteriorating health and lack of incentives. Facilitators to successful IAC were Capability - good knowledge of ART, good memory, and reminder alerts; Opportunity - availability of ART, social support, availability of ART, prolonged ART refill, and good counseling; and Motivation - desire to live longer and healthy and the desire to fulfill dreams and goals. Successful implementation of IAC needs to consider the context of the person in care thus the need to strengthen individualized IAC sessions. HIV care providers can adopt the COM-B framework to perform individualized IACs and use the information to strengthen the counseling sessions.

Comparison of Older and Younger Patients Referred to a Non-interventional Community Pain Clinic in the Greater Toronto Area (GTA).

To compare demographic and pain characteristics of older (≥ 65) vs younger (< 65) chronic non-cancer pain patients referred to a community pain clinic in the Greater Toronto Area (GTA), Ontario, Canada. This is a retrospective study of 644 consecutive new patients with pain seen during 2016-2017 (older group n = 126; younger group n = 518). Demographic characteristics, Brief Pain Inventory pain ratings, and diagnosis were obtained using retrospective chart review. Patients were classified into groupI (pure biomedical pathology), groupII (mixed biomedical causes and psychological factors) and groupIII (no detectable physical pathology but psychological factors were considered important). Older patients comprised 19.6% of the overall population (higher than the average GTA older population). Regarding older vs younger group, male/female ratio was 1:1.3 vs 1:1.7 respectively, while 71% of the older patients were foreign born vs 37% of the younger group (p < 0.001). Low back was the most prevalent pain site for both groups; 70% of the older patients were classified as groupI vs 35% of the younger patients (p < 0.0001), and only 6% as groupIII (vs 18% of the younger population, p < 0.05). The study points to considerable differences between younger and older patients with pain with the latter presenting with significant biomedical pathology but lesser psychopathology. The results are comparable to those obtained from a university pain clinic as well as a rural Northern Ontario clinic. Implications of the study for planning of pain care are discussed.

Drinking Water Arsenic, Hemoglobin, and Anemia among Pregnant Women in Rural Northern Bangladesh

Drinking Water Arsenic, Hemoglobin, and Anemia among Pregnant Women in Rural Northern Bangladesh

Class, Conservation, and the Police Power in the American Gilded Age: The Origins of Lawton v. Steele

Abstract The leading police power case of Lawton v. Steele, decided by the US Supreme Court in 1894, offers insight into the question of judicial class bias during the decades following the Civil War. Conflict arose in rural northern New York State over restrictions on livelihood fishing by nets imposed to protect sport angling by affluent tourists. Opposition to the restrictions was grounded in a producerist worldview and class consciousness. The matter reached the courts in a challenge to state laws permitting the summary destruction, without legal process, of nets placed illegally. Seemingly prohibited by the Fourteenth Amendment and previous case law, such destruction was upheld by a Supreme Court divided along ideological lines, correlating with the justices’ Whig or Jacksonian antecedents. The dissenters, those of Jacksonian sympathies, argued unsuccessfully against the challenged laws.

Infant mortality and risk factors in Nigeria in 2013-2017: A population-level study.

SummaryBackgroundGlobally, over the past two decades, many countries have significantly reduced the rate of infant mortality. Yet, in Africa, Nigeria remains one of the countries with the highest infant mortality rate (IMR).MethodsWe conducted a population-level study using the 2018 Nigeria Demographic Health Survey (NDHS). A total of 41,668 household data were analyzed retrospectively. The association between each exposure and infant mortality was analyzed in logistic regression models (independently adjusted by demographic and socioeconomic status variables) and confirmed by the multiple comparisons analysis.FindingsThe overall IMR of 2013–2017 was 61.5 (95% CI 58.0, 65.3) per 1000 live births. In general, the North-West and North-East regions had the highest IMR, whereas the South-West, South-East and South-South regions had the lowest IMR. The regression analysis found women who delivered their babies at the age <=18 years old (odds ratio (OR): 1.37 [1.17, 1.62]), had religion of Islam (OR: 1.35 [1.10, 1.65]), no ANC visit (OR: 1.69 [1.21, 2.35]), >4 ANC visits (OR: 1.70 [1.23, 2.34]), ANC not at home or skilled provider (0.40 [0.35, 0.46]) and the babies as the first child (OR: 1.23 [1.07, 1.42]) to be associated with higher IMR.InterpretationOur findings imply that Nigeria is not on track to achieving the SDG target of reducing child mortality by 2030. Sustainable interventions are urgently needed to address the challenges for women of reproductive age, particularly those that are living in the rural areas and Northern regions, having limited/no access to health care/skilled providers, and delivered their first child.FundingNone.

Intake of Fruits, Vegetables, and Sugar-Sweetened Beverages among a Sample of Children in Rural Northern Ontario, Canada.

There is evidence to suggest that dietary intake of children differs by rural/urban place of residence: rural children may have a higher intake of foods high in fat and sugar than those living in urban environments. The aim of this study was to examine the intake of fruits and vegetables (FV) and the frequency of sugar-sweetened beverage (SSB) consumption, among a sample of rural children in Northern Ontario, Canada, in two different seasons. Sociodemographic factors and children’s FV and SSB intake were measured using two repeated cross-sectional surveys, and seasonal information was based on the month of data collection. Logistic regressions were used to examine the odds of children eating five or more FVs, and the odds of ‘frequently or always’ consuming SSBs. During the fall, children reported eating five or more FV more often, when compared to winter (53.9% vs. 48.3%). In the fall, 25.8% of children reported ‘frequently or always’ drinking SSB, compared with 16.9% in winter. Indigenous children were less likely to eat five or more FV (OR 0.34 (95% CI 0.12–0.95)) in the fall when compared to non-Indigenous children. Findings indicate that intake of FV among rural students in this region is low, and the frequency of SSB is high, when compared with national recommendations.

Relationship Between Hypertension and Cognitive Function in an Elderly Population: A Population-Based Study in Rural Northern China.

The burden of cognitive impairment and dementia is particularly severe in low- and middle-income countries. Although hypertension is an important risk factor for cognitive impairment, the influence of different hypertension classification on cognitive impairment remains controversial. To explore the impact of hypertension and hypertension classification on cognitive function, this study was based on a low-income population aged over 60 years in northern China. This population-based, cross-sectional study was conducted from April 2014 to January 2015 in rural areas of Tianjin, China. A total of 1,171 participants aged ≥ 60 years were included. Participants were interviewed by professional researchers face-to-face, using the pre-designed questionnaire. Cognitive function was assessed using the Mini-mental State Examination (MMSE). Multivariate regression analysis was used to calculate the odds ratio (OR) value. There was a significant association between hypertension and cognitive impairment (OR, 1.415; 95% CI: 1.005–1.992; P = 0.047) and a significant positive association between stage 3 hypertension (OR, 1.734; 95% CI: 1.131–2.656; P = 0.012) and the prevalence of cognitive impairment. To prevent dementia, clinicians should consider the cognitive function and blood pressure control of low-income individuals aged over 60 years with hypertension in northern China, especially those with stage 3 hypertension. In addition, the inconsistent effects of blood pressure on different cognitive functions should also be considered; special attention should be paid to orientation and concentration.

Like wildfire: creating rumor content in the face of disaster

ABSTRACT Rumors spread during disasters as community members seek information and attempt to make sense of unexpected, anxiety-producing events. While considerable sociological research has examined the transmission and spread of rumors, less attention has been given to the creation of rumor narrative content itself. Drawing on interviews with wildfire survivors in one rural Northern California county, this study shows that rumor narrative creation reflects existing cultural values and power arrangements. In a contested post-disaster landscape, rumors are used to frame new information to maintain coherence with existing cultural beliefs while reinforcing prevailing ideas about safety, deservingness, and class. In this case, rumors are created to reflect cultural schemas such as beliefs about the government and environmental protection, and normative power arrangements instantiated through symbols of spatial stigma. The data presented in this article extends research on stigma, culture, and disaster by arguing existing dominant cultural values shape the content of rumors by dictating which pieces of information are seen as reasonable and reliable, providing residents with opportunities to frame information to explain and justify unequal disaster outcomes. In disaster situations where the transmission of reliable information is especially important, local culture enables and restricts which narratives are produced, shared, and believed.

Using the Technology Acceptance Model to Characterize Barriers and Opportunities of Telemedicine in Rural Populations: Survey and Interview Study.

BackgroundHealth care access issues have long plagued rural Americans. One approach to alleviating the challenges and poor health outcomes for rural individuals is through the use of telemedicine, sometimes called telehealth. It is important to understand factors that may be related to telemedicine adoption or nonadoption, particularly in underserved rural settings.ObjectiveThis pilot study examines telemedicine perceptions among rural, underserved populations using the Technology Acceptance Model, which serves as a framework to explore the adoption of telemedicine services by those who have used it. This study also explores the differences between user and nonuser perceptions of telemedicine.MethodsPaper surveys and phone interviews were conducted in rural Northern Lower Michigan.ResultsPerceived usefulness and perceived ease of use explained 91% of the variability in attitude toward telemedicine (R2=0.91; F1,15=73.406; P<.001). Ease of use was a significant predictor (mean 2.36, SD 1.20; P<.001), but usefulness (mean 3.16, SD 0.81; P=.20) was not. Furthermore, there were significant differences in individual perception of telemedicine between users and nonusers. For example, nonusers believed they would receive better care in person (users: mean 3.30, SD 1.22; nonusers: mean 1.91, SD 1.14; F1,32=10.126; P=.003). The quantitative findings were reinforced by the qualitative results from the phone interviews.ConclusionsOverall, the Technology Acceptance Model is an appropriate model to understand the attitudes toward telemedicine that may lead to its adoption by rural Americans.

"I've been to more of my friends' funerals than I've been to my friends' weddings": Witnessing and responding to overdose in rural Northern New England.

Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed-methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in-depth interviews (n = 22). Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality.

The impact of depressive symptoms and social support on resilience among older adult caregivers

In this study the authors explored how depressive symptoms and social support were related to the resilience of older caregivers (N = 117) caring children affected by HIV/AIDS in rural Northern Namibia, Africa. Our findings showed that lower levels of depressive symptoms and high levels of social support from significant others and family were statistically associated with increased resilience in older caregivers. There is a need for mental health services and social supports to improve the resilience of older caregivers caring for children affected by HIV and AIDS. There is an increasing need for more vigorous and concerted efforts from public and private sector practitioners and policy makers to expand social protection safety nets and develop more targeted economic interventions aimed at enhancing the resilience of older caregivers, especially those residing in rural HIV endemic communities in Namibia.

Talking together in rural palliative care: a qualitative study of interprofessional collaboration in Norway

BackgroundCaring for people with palliative care needs in their homes requires close collaboration within and between primary and hospital care. However, such close collaboration is often lacking. Transitions of care are potentially unsafe and distressing points in a patient trajectory. Few studies have explored the experiences of healthcare professionals in the community who receive patients from hospital care and provide them with palliative care at home.ObjectiveTo explore how rural health professionals experience local and regional collaboration on patients in need of palliative care.MethodsThis was a qualitative focus group and interview study in rural Northern Norway involving 52 primary care health professionals including district nurses, general practitioners, oncology nurses, physiotherapists, and occupational therapists. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.Results“Talking together” was perceived as the optimal form of collaboration, both within primary care and with specialists. Nurses and GPs had similar perceptions of their worst-case scenario in primary palliative care: the sudden arrival after working hours of a sick patient about whom they lacked information. These situations could be the result of a short notice transfer from secondary care or an emergency presentation after a crisis in patient management locally, the latter often resulting in a hospital admission. Participants missed timely and detailed discharge letters and in complex cases a telephone call or conference. Locally, co-location was perceived as advantageous for crucial communication, mutual support, and knowledge about each other’s competencies and work schedule. Because local health professionals belonged to different units within the primary health care organisation, in some places they had limited knowledge about each other’s roles and skill sets.ConclusionsLack of communication, both locally and between specialist and primary care, was a key factor in the worst-case patient scenarios for GPs and nurses working in primary palliative care in rural Northern Norway. Co-location of primary care professionals promoted local collaboration and should be encouraged. Hospital discharge planning should involve the receiving primary care professionals.

A New Professional Ethos: E-commerce and Business Culture in a County of Rural Northern China

After a phase of slow development, e-commerce has become widespread in rural China, being promoted by both local governments and corporations. How has it changed business culture and business networks? Based on an ethnographic study conducted in a rural county in Henan, the article explores shifts in patterns of group formation and identity among local businesspeople. Fieldwork included 60 interviews with e-retailers, manufacturers, and local officials, as well as participant observation conducted from 2016 to 2019. The study suggests that online retailing has fostered the emergence of a shared ethos, which values quality and professionalism rather than the ability to build strong interpersonal ties through leisure and credit practices. This new ethos, congruent with state-sponsored, nationwide shifts in the economic structure, entails the emergence of a more far-flung integrated business community, while accentuating local processes of social differentiation.

Demographic and Regional Trends of Smoking among Thai Females from 1986 to 2014

&#x0D; Background: Smoking is a major public health burden causing substantial morbidity and mortality. The aim of the study was to assess the prevalences and demographic trends of smoking among Thai females. &#x0D; Methods Data from Thailand’s National Statistics Office for 1986 to 2014 were used. Multiple logistic regression was implemented to identify the prevalences and trends of female smoking by region (Bangkok, Central, Northeast, North, and South) and area (Rural and Urban). &#x0D; Results: The overall prevalence of smoking was 3.4% among females aged 15 years and above in 2014. Gradually decreasing trends of smoking were observed from 1991 to 2007. Afterwards, the trends of smoking was found higher in 2011 to 2014 among aged 15-39 years. Furthermore, there were substantial differences in female smoking in different regions and areas. Of those, the Northern Thailand and rural areas had the highest prevalence of smokers. &#x0D; Conclusion: Smoking among Thai females in the past 20 years had a decreasing trend, but it can be seen that since 2007 the trend of smoking had shown an increasing trend and a variation among the regions. This imply that, tobacco control policies are important and in need particularly for young females, living in rural areas and Northern provinces. &#x0D;

Building a Foundation for the Care of Children with Cancer in Rural North India

AbstractOne of India's biggest challenges is to improve its global standing by increasing healthcare access and outcomes for children with cancer, with inferior overall survivorship compared with its Western counterparts. In conjunction with the government's efforts, private enterprise is crucial in delivering optimal cancer care consistently to its vast and diverse pediatric population, despite existing limitations. This article describes the successful implementation of a value-based, collaborative clinical and research framework by a philanthropic foundation in a rural Northern Indian city to establish and run a local childhood cancer service. It is proof of concept that substantial change could be brought about at grass roots level through resourceful partnerships and reduce prevailing imbalance in pediatric oncology service provision.

The Association Between the Prevalence, Medication Adherence and Control of Hypertension and the Prevalence of Mild Cognitive Impairment in Rural Northern China: A Cross-Sectional Study.

IntroductionHigh blood pressure is one of the main modifiable risk factors for dementia. However, it remains unclear whether lowering the blood pressure effectively prevents cognitive impairment. Our objective was to explore the association between the prevalence, medication adherence and control of hypertension and mild cognitive impairment (MCI) among elderly individuals in northern China.MethodsA two-stage clustering sampling method was used, and 9036 participants aged ≥65 years were included in the analysis. The Mini-Mental State Examination and activities of daily living were used to assess participants’ cognitive function. Demographic characteristics (gender, age, marital status, education level, occupation), history and duration of hypertension, use of antihypertensive medications (AHMs) and its control effect were obtained.ResultsThe prevalence of MCI in all participants was 18.1%, and the prevalence of MCI was significantly higher in hypertensive subjects than in normotensive subjects (19.7% vs 16.2%, P < 0.01). Furthermore, in hypertensive patients, the prevalence of MCI was lower in those with good adherence (17.3%) than in those with poor adherence (23.7%, P < 0.01) and lower in those controlled (16.5%) than in those with uncontrolled adherence (20.8%, P < 0.01). In univariate analyses, being female gender, increased age, agriculture occupation, unmarried and widow, less than primary school and middle school were associated with MCI prevalence. The assessment of the hypertensive patients revealed the adjusted OR (95% CI) of having MCI in those with poor adherence to AHMs was 1.32 (1.14–1.54) compared with those having good adherence.ConclusionThere is an association between the prevalence of hypertension, adherence to AHMs and MCI, suggesting that hypertensives should be screened for MCI to provide improved diagnoses and optimal therapeutics for cognitive decline prevention, especially in poor AHM adherence.

Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana.

Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana's ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.

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.