Reconceptualising risk: perceptions of risk in rural and remote maternity service planning (original) (raw)
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Obstetric services in small rural communities: what are the risks to care providers
Introduction: In spite of a sharp decline, since 2000, in the number of rural communities in Canada that offer local maternity care, there remain significant numbers of small rural maternity services that provide elective maternity care without on-site access to cesarean section. In communities with an elective maternity service without local access to surgical capability, practitioners must be prepared to respond to obstetrical emergencies and arrange urgent transfer if a cesarean section is indicated. In most cases reasonably safe care can be provided by this model, but the possibility of an unexpected emergency that threatens the fetus or mother always exists. Although there is an emerging understanding of the stressors faced by rural physicians, little is known about the experience of care providers offering maternity care in low-resourced environments. This article considers the experience of rural maternity care providers from the perspective of the social risks they perceive are incurred by practicing in a low-resource environment. Methods: A qualitative exploratory approach was employed, using in-depth interviews and focus groups with care providers in three rural communities in British Columbia, Canada. The transcripts were thematically analyzed in four stages. Results: Twenty-six care providers were interviewed across the three communities, including 15 nurses and 11 physicians. Participants identified elements of personal risk they perceived were assumed by offering intra-partum care in communities without local access to cesarean section back up, and the potential effects of these risks on themselves and their communities. They © JA Kornelsen, SW Grzybowski, 2008. A licence to publish this material has been given to ARHEN http://www.rrh.org.au 2 further recognized the unique attributes of maternity care, which, when juxtaposed with other aspects of primary care, led to a heightened sense of social risk in a rural environment. Conclusion: A balanced approach to risk management grounded in a comprehensive understanding of the values that influence decision-making, including acknowledgement of the social risks care providers incur, is a necessary step towards better health services for rural parturient women and their babies. Additional strategies may include community-based identification of the risks and benefits of local care, and programs of professional support for rural obstetrical care providers experiencing stress.
Rural Women's Experiences of Maternity Care: Implications for Policy and Practice
This research investigated rural maternity care from the perspective of parturient women, care providers, health care administrators and local leaders. We found that women's experiences were bound in the complexity of relationships that were influenced by the attitudes and actions of care providers and the organization of health system services. The study took place within a dynamically changing health care environment in which three of the four study sites ceased offering birthing services during the course of the project. The lack of clearly defined policies supporting rural maternity care was reflected in a tenuous infrastructure for local birthing. This left local services vulnerable to the vagaries of practitioner's attitudes, critical incidents, the variable social and historical context of the community and geography. Literature on risk assessment provides a lens through which some of the findings may be interpreted.
Cultures of risk and their influence on birth in rural British Columbia
BMC Family Practice, 2012
Background: A significant number of Canadian rural communities offer local maternity services in the absence of caesarean section back-up to parturient residents. These communities are witnessing a high outflow of women leaving to give birth in larger centres to ensure immediate access to the procedure. A minority of women choose to stay in their home communities to give birth in the absence of such access. In this instance, decision-making criteria and conceptions of risk between physicians and parturient women may not align due to the privileging of different risk factors. Methods: In-depth qualitative interviews and focus groups with 27 care providers and 43 women from 3 rural communities in B.C. Results: When birth was planned locally, physicians expressed an awareness and acceptance of the clinical risk incurred. Likewise, when birth was planned outside the local community, most parturient women expressed an awareness and acceptance of the social risk incurred due to leaving the community. Conclusions: The tensions created by these contrasting approaches relate to underlying values and beliefs. As such, an awareness can address the impasse and work to provide a resolution to the competing prioritizations of risk.
BMC Health Services Research, 2017
Background: Australia has a universal health care system and a comprehensive safety net. Despite this, outcomes for Australians living in rural and remote areas are worse than those living in cities. This study will examine the current state of equity of access to birthing services for women living in small communities in rural and remote Australia from a population perspective and investigates whether services are distributed according to need. Methods: Health facilities in Australia were identified and a service catchment was determined around each using a one-hour road travel time from that facility. Catchment exclusions: metropolitan areas, populations above 25,000 or below 1,000, and a non-birthing facility within the catchment of one with birthing. Catchments were attributed with population-based characteristics representing need: population size, births, demographic factors, socio-economic status, and a proxy for isolation -the time to the nearest facility providing a caesarean section (C-section). Facilities were dichotomised by service levelthose providing birthing services (birthing) or not (no birthing). Birthing services were then divided by C-section provision (C-section vs no C-section birthing). Analysis used two-stage univariable and multivariable logistic regression. Results: There were 259 health facilities identified after exclusions. Comparing services with birthing to no birthing, a population is more likely to have a birthing service if they have more births, (adjusted Odds Ratio (aOR): 1.50 for every 10 births, 95% Confidence Interval (CI) [1.33-1.69]), and a service offering C-sections 1 to 2 h drive away (aOR: 28.7, 95% CI [5.59-148]). Comparing the birthing services categorised by C-section vs no C-section, the likelihood of a facility having a C-section was again positively associated with increasing catchment births and with travel time to another service offering C-sections. Both models demonstrated significant associations with jurisdiction but not socio-economic status. Conclusions: Our investigation of current birthing services in rural and remote Australia identified disparities in their distribution. Population factors relating to vulnerability and isolation did not increase the likelihood of a local birthing facility, and very remote communities were less likely to have any service. In addition, services are influenced by jurisdictions.
Rural maternity care and health policy: Parents' experiences
Australian Journal of Rural Health, 2011
Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty-three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (a) increased financial costs; (b) family issues; and (c) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re-evaluated in order to improve rural Australians' access to vital health services such as maternity care.
Health policy: outcomes for rural residents' access to maternity care
2009
Regular health care during pregnancy, birthing and the postnatal period is recommended for improving maternal and neonatal outcomes and accessing such care has become a common expectation for Australian families. Studies have highlighted the relative safety of birthing ...
Primary Maternity Units in rural and remote Australia: Results of a national survey
Midwifery, 2016
Background Primary maternity units (PMUs) offer less expensive and potentially more sustainable maternity care, with comparable or better perinatal outcomes for normal pregnancy and birth than higherlevel units. However, little is known about how these maternity services operate in rural and remote Australia, in regards to location, models of care, service structure, support mechanisms or sustainability. This study aimed to confirm and describe how they operate. Design A descriptive, cross-sectional study was undertaken, utilising a 35-item survey to explore current provision of maternity care in rural and remote PMUs across Australia. Data were subjected to simple descriptive statistics and thematic analysis for free text answers. Setting and Participants: Only 17 PMUs were identified in rural and remote areas of Australia. All 17 completed the survey. Results The PMUs were, on average, 56km or 49 minutes from their referral service and provided care to an average of 59 birthing women per year. Periodic closures or downgrading of services was common. Low-risk eligibility criteria were universally used, but with some variability. Medically-led care was the most widely available model of care. In most PMUs midwives worked shift work involving both nursing and midwifery duties, with minimal uptake of recent midwifery workforce innovations. Perceived enablers of, and threats to, sustainability were reported. Key Conclusions and Implications for Practice A small number of PMUs operate in rural Australia, and none in remote areas. Continuing overreliance on local medical support, and under-utilisation of the midwifery workforce constrain the restoration of maternity services to rural and remote Australia.
Local birthing services for rural women: Adaptation of a rural New South Wales maternity service
Australian Journal of Rural Health, 2016
Objective: To 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). Design: A retrospective descriptive study using quantitative methodology. Setting: Maternity unit in a small public hospital in rural New South Wales, Australia. Participants: Data were extracted from the wardbased birth register for 1172 births at the service between July 2007 and June 2012. Main outcome measures: Birth numbers, maternal characteristics, labour, birthing and neonatal outcomes. Results: There 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. Conclusion: This 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.
Identifying maternity services in public hospitals in rural and remote Australia
Australian health review : a publication of the Australian Hospital Association, 2014
Objective. This paper articulates the importance of accurately identifying maternity services. It describes the process and challenges of identifying the number, level and networks of rural and remote maternity services in public hospitals serving communities of between 1000 and 25 000 people across Australia, and presents the findings of this process.