4.1 The safety of Canadian rural maternity services- a multi-jurisdictional cohort analysis

Abstract

Background

Canadian rural maternity services face significant challenges, including maintaining adequate staffing levels and ensuring operational viability. Adverse maternal and newborn outcomes are frequently linked to the necessity of travel to access these services, highlighting the importance of local care accessibility.

Study Goal

The primary goal of this study is to systematically assess maternal and newborn health outcomes across three Canadian provinces - British Columbia, Alberta, and Nova Scotia, seeking to identify trends and factors affecting rural maternity care.

Introduction

Rural Maternity Services Struggles

Over the past 15 years, there has been a documented and significant reduction in the availability of small maternity services in rural Canada. Notably, British Columbia has experienced 20 closures of these vital services since the year 2000, which has created critical gaps in maternal healthcare in remote communities.

Reasons for Decline

Several key reasons have been identified that contribute to the decline of rural maternity services:

• Recruitment Difficulties: Rural areas often struggle to attract and retain health care providers, resulting in reduced service availability.

• Quality Concerns: There are pervasive quality concerns regarding maternal and newborn outcomes in smaller facilities, which can affect public perception and utilization of services.

• Regionalization and Centralization: An increasing emphasis on regionalization and centralization of services has shifted care away from local settings, often at the cost of access for rural women.

Existing research shows that small maternity services are capable of providing high-quality care, even in the absence of local caesarean section capabilities, indicating that these facilities play a crucial role in rural healthcare.

Methods

Data Collection

The study analyzes maternal and newborn outcomes derived from provincial perinatal registries covering the years 2003 to 2008. Important exclusions from the data include:

• Metropolitan areas

• Multiple births

• Infants diagnosed with congenital anomalies

Catchment areas were determined based on mothers’ residential postal codes in British Columbia and Alberta, and geocoding was utilized for Nova Scotia.

Service Levels Defined by Distance

A classification of service levels based upon travel distance to maternity services is established as follows:

Analysis

Statistical methods employed in the analysis include logistic regression, with adjustments made for relevant maternal factors to ensure accurate outcomes interpretation. Data processing tools such as SPSS and SAS were utilized to facilitate robust analysis.

Ethics approval for the study was obtained from the respective health ethics boards in Alberta, Nova Scotia, and British Columbia, ensuring that the research adhered to ethical standards and protected participant confidentiality.

Results

Total Singleton Births Analyzed

The study analyzed a total of 150,797 singleton births, with the following distribution:

• Alberta: 70,037 births

• British Columbia: 61,991 births

• Nova Scotia: 18,769 births

Perinatal Mortality

Notably, perinatal mortality rates were found to be highest in communities situated more than 4 hours from the nearest maternity services, illustrating the critical impact of distance on health outcomes.

Prematurity Rates

Prematurity rates were significantly higher for rural women who lacked local access to maternity services, further exacerbated by the distance to such essential care offerings.

Intervention Rates

The analysis revealed that caesarean section rates were highest in communities that relied on general surgical models, while lower intervention rates were recorded in communities situated further from services.

Demographics

Variations in demographic characteristics, including maternal age, parity (number of pregnancies), and prevailing health conditions, were noted across different jurisdictions, potentially influencing care and outcomes.

Discussion

Centralization vs. Local Services

The findings raise critical questions regarding the effectiveness of centralizing maternity care services, suggesting that maintaining local access may offer better outcomes for rural mothers and infants.

Policy Recommendations

To foster improvements in rural maternal healthcare, the following policy recommendations are proposed:

• Halting Closures: A call to stop the closure of existing rural maternity services and provide necessary support for those that continue to operate.

• Enhanced Training Advocacy: Advocating for enhanced surgical training for healthcare providers in rural areas to ensure necessary skills and competencies for local procedures.

Study Limitations

The study acknowledges certain limitations, such as data variability across jurisdictions that hinders comprehensive conclusions, in addition to a lack of ethnic and socio-economic adjustments in the analysis.

Conclusion

The findings underscore the necessity of sustaining small community maternity services in rural Canada as a vital strategy for improving maternal and newborn outcomes. Supporting rural surgical services, particularly those staffed by GPs equipped with enhanced skills, is considered essential for providing safe obstetric care in diverse and geographically challenging landscapes.