Lessons learned from the COVID-19 pandemic: The importance of physician leadership in responding to rural community ecosystem disruptions

INTRODUCTION

The COVID-19 pandemic presented an unprecedented challenge for rural family physicians. The lessons learned over the course of 2 years have potential to help guide responses to future ecosystem disruption. This qualitative study aims to explore the leadership experiences of rural Canadian family physicians during the COVID-19 pandemic as both local care providers and community health leaders and to identify potential supports and barriers to physician leadership.

METHODS

Semi-structured, virtual, qualitative interviews were completed with participants from rural communities in Canada from December 2021 to February 2022 inclusive. Participant recruitment involved identifying seed contacts and conducting snowball sampling. Participants were asked about their experiences during the COVID-19 pandemic, including the role of physician leadership in building community resilience. Data collection was completed on theoretical saturation. Data were thematically analysed using NVivo 12.

RESULTS

Sixty-four participants took part from 22 rural communities in 4 provinces. Four key factors were identified that supported physician leadership towards rural resilience during ecosystem disruption: (1) continuity of care, (2) team-based care models, (3) physician well-being and (4) openness to innovative care models.

CONCLUSION

Healthcare policy and practice transformation should prioritise developing opportunities to strengthen physician leadership, particularly in rural areas that will be adversely affected by ecosystem disruption.

INTRODUCTION

La pandémie de COVID-19 a représenté un défi sans précédent pour les médecins de famille en milieu rural. Les leçons tirées au cours des deux années écoulées peuvent aider à orienter les réponses aux futures perturbations de l'écosystème. Cette étude qualitative vise à explorer les expériences de leadership des médecins de famille ruraux canadiens pendant la pandémie de COVID-19, en tant que prestataires de soins locaux et chefs de file de la santé communautaire, et à identifier les soutiens et les obstacles potentiels au leadership des médecins.

MTHODES

Des entretiens qualitatifs virtuels semi-structurés ont été réalisés avec des participants issus de communautés rurales du Canada entre décembre 2021 et février 2022 inclus. Le recrutement des participants a consisté à identifier des contacts de base et à procéder à un échantillonnage boule de neige. Les participants ont été interrogés sur leurs expériences durant la pandémie de COVID-19, notamment sur le rôle du leadership des médecins dans le renforcement de la résilience des communautés. La collecte des données s'est achevée après saturation théorique. Les données ont été analysées thématiquement à l'aide de NVivo 12.

RSULTATS

Soixante-quatre participants provenant de 22 communautés rurales de quatre provinces ont pris part à l'étude. Quatre facteurs clés ont été identifiés pour soutenir le leadership des médecins en faveur de la résilience rurale en cas de perturbation de l'écosystème: (1) la continuité des soins, (2) les modèles de soins en équipe, (3) le bien-être des médecins et (4) l'ouverture à des modèles de soins novateurs.

CONCLUSION

La politique de santé et la transformation des pratiques devraient donner la priorité au développement d'opportunités pour renforcer le leadership des médecins, en particulier dans les zones rurales qui seront négativement affectées par la perturbation de l'écosystème.

Feasibility issues impacting optimal levels of maternity care in rural communities: implementing the Rural Birth Index in British Columbia

INTRODUCTION

The continued attrition of maternity services across rural communities in high resource countries demands a rigorous, systematic approach to determining population level need, including a clear understanding of feasibility issues that may constrain achieving and sustaining recommended levels of services. The Rural Birth Index (RBI) proposes a robust and objective methodology to determine such need along with attention to the feasibility of implementation.

BACKGROUND

Predictions of appropriate levels of maternity care in rural communities require consideration of the feasibility of implementation. Although previous work has focused on essential considerations that impact feasibility, there is little research documenting the barriers to implementation from the perspective of rural care providers and administrators.

METHODS

We conducted in-depth, qualitative research interviews with rural community health care administrators and providers (n = 14) to understand the challenges of offering maternity care in 10 rural communities across British Columbia (BC).

RESULTS

Participants articulated three thematic challenges to providing maternity services in their communities: maintaining clinical skills and financial stability in the context of low procedural volume, recruitment and retention of care providers and challenges with patient transport.

CONCLUSIONS

Current models of compensation for maternity care are inadequate and inflexible and underscore many of the challenges to implementing a level of care that is based on population need. Re-thinking provision of care as a social obligation to actualize our system commitment to equity instead of working to achieve economies of scale is the first step to use equitable care. Addressing remuneration will provide the groundwork for solving other barriers to sustainable care.

What makes a healthy rural community?

Introduction

Health outcomes in rural populations are known to be generally worse than in urban populations but there are some exceptions to this trend. Most research evaluating these disparities has focused on rural communities with poor health outcomes. The current study set out to explore the factors that make some rural communities healthier than others.

Methods

Semi-structured interviews were conducted with a purposive sample of 12 key informants in a rural community within a healthy outlier region. The interview guide was based on the Social-Ecological Model of health and the focus was on community - as opposed to facility-based health. Interview data were analysed using directed content analysis.

Results

Five main themes were identified: (1) availability of amenities, (2) healthy lifestyle as a shared value, (3) transition from a mining community, (4) geographic location and (5) challenges.

Conclusion

Many of the findings challenge traditional assumptions about determinants of health in rural communities. The phenomenon of 'amenity migration' from urban to rural areas which may increase in coming years, is one that can have important implications for health.

Standardised early warning scores in rural interfacility transfers: A pilot study into their potential as a decision-making aid

Introduction

While 12.4% of British Columbians live rurally, only 2.0% of specialists practise rurally, making interfacility transport of high-acuity patients vital. Decision-making aids have been identified as a way to improve the interfacility transfer process. We conducted a pilot study to explore the potential of the Standardised Early Warning Score (SEWS) as a decision-making aid for staff at sending facilities.

Methods

SEWSs were calculated from a database of 418 transfers from sending facilities in rural, small and medium population centres to larger receiving facilities. The SEWSs were compared against one another over time using McNemar's and the Wilcoxon signed-ranks tests. The SEWSs were then tested for their association with six outcomes using Pearson's or Fisher's Chi-squared test and the Mann-Whitney U-test.

Results

While at the sending facility, both the number of SEWSs that was four or greater and the average SEWS decreased over time (P < 0.001 for both). A first SEWS of four or greater was predictive of more intervention categories during transport (P = 0.047), an adverse event during transport (P = 0.004), an adverse event within 30 min of arrival at the receiving facility (P = 0.004) and death before discharge from the receiving facility (P = 0.043) but not deterioration during transport, or the length of stay at the receiving facility.

Conclusion

Overall, the performance of the SEWS in the context of rural interfacility transport suggests that the tool will have utility in supporting decision-making.

High acuity rural transport: findings from a qualitative investigation

INTRODUCTION

The High Acuity Response Team (HART) was introduced in British Columbia (BC), Canada, to fill a gap in transport for rural patients that was previously being met by nurses and physicians leaving their communities to escort patients in need of critical care. The HART team consists of a critical care registered nurse (CCRN) and registered respiratory therapist (RRT) and attends acute care patients in rural sites by either stabilizing them in their community or transporting them. HART services are deployed in partnership with provincial ambulance services, which provide vehicles and coordination of all requests in the province for patient transport. This article presents the qualitative findings from a research evaluation of the efficacy of the HART model, including staffing and inter-organizational functioning.

METHOD

Open-ended qualitative research interviewing was done with key stakeholders from 21 sites. Research participants included HART CCRNs, RRTs, administrative leads, as well as local emergency department (ED) physicians and nurses. Thematic analysis was done of the transcripts.

RESULTS

A total of 107 interviews in 21 study sites were completed. Participants described characteristics of the model, perceptions of efficacy and areas for improvement. Rural sites reported a decrease in physician- and nurse-accompanied transports for high-acuity patients due to the HART team, but also noted challenges in delayed deployment, sometimes leading to adverse patient outcomes.

CONCLUSIONS

The salient issues for the HART model were grounded in a somewhat artificial distinction between pre-hospital and interfacility transport for rural patients, which leads to a lack of service coordination and potentially avoidable delays. A beneficial systems change would be to move towards dedicated integration of high-acuity transport services into hospital organizational structures and community health services in rural areas.

The distribution of maternity services across rural and remote Australia: does it reflect population need?

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 level – those 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.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2084-8) contains supplementary material, which is available to authorized users.

Rural health service planning: the need for a comprehensive approach to costing

The precipitous closure of rural maternity services in industrialized countries over the past two decades is underscored in part by assumptions of efficiencies of scale leading to cost-effectiveness. However, there is scant evidence to support this and the costing evidence that exists lacks comprehensiveness. To clearly understand the cost-effectiveness of rural services we must take the broadest societal perspective to include not only health system costs, but also those costs incurred at the family and community levels. We must consider manifest costs (hard, easily quantifiable costs, both direct and indirect) and latent costs (understood as what is sacrificed or lost), and take into account cost shifting (reallocating costs to different parts of the system) and cost downloading (passing costs on to women and families). Further, we must compare the costs of having a rural maternity service to those incurred by not having a service, a comparison that is seldom made. This approach will require determining a methodological framework for weighing all costs, one which will likely involve attention to the rich descriptions of those experiencing loss.

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

Background

Small Canadian rural maternity services are struggling to maintain core staffing and remain open. Existing evidence states that having to travel to access maternity services is associated with adverse outcomes. The goal of this study is to systematically examine rural maternal and newborn outcomes across three Canadian provinces.

Methods

We analyzed maternal newborn outcomes data through provincial perinatal registries in British Columbia, Alberta and Nova Scotia for deliveries that occurred between April 1st 2003 and March 31st 2008. All births were allocated to maternity service catchments based on the residence of the mothers. Individual catchments were stratified to service levels based on distance to access intrapartum maternity services or the model of maternity services available in the community. The amalgamation of analyses from each jurisdiction involved comparison of logistic regression effect estimates.

Results

The number of singleton births included in the study is 150,797. Perinatal mortality is highest in communities that are greater than 4 h from maternity services overall. Rates of prematurity at less than 37 weeks gestation are higher for rural women without local access to services. Caesarean section rates are highest in communities served by general surgical models.

Conclusion

Composite analysis of data from three Canadian provinces provides the strongest evidence to date demonstrating that we need to sustain small community maternity services with and without caesarean section capability.

Rural maternity care

OBJECTIVE

To provide an overview of current information on issues in maternity care relevant to rural populations.

EVIDENCE

Medline was searched for articles published in English from 1995 to 2012 about rural maternity care. Relevant publications and position papers from appropriate organizations were also reviewed.

OUTCOMES

This information will help obstetrical care providers in rural areas to continue providing quality care for women in their communities. Recommendations 1. Women who reside in rural and remote communities in Canada should receive high-quality maternity care as close to home as possible. 2. The provision of rural maternity care must be collaborative, woman- and family-centred, culturally sensitive, and respectful. 3. Rural maternity care services should be supported through active policies aligned with these recommendations. 4. While local access to surgical and anaesthetic services is desirable, there is evidence that good outcomes can be sustained within an integrated perinatal care system without local access to operative delivery. There is evidence that the outcomes are better when women do not have to travel far from their communities. Access to an integrated perinatal care system should be provided for all women. 5. The social and emotional needs of rural women must be considered in service planning. Women who are required to leave their communities to give birth should be supported both financially and emotionally. 6. Innovative interprofessional models should be implemented as part of the solution for high-quality, collaborative, and integrated care for rural and remote women. 7. Registered nurses are essential to the provision of high-quality rural maternity care throughout pregnancy, birth, and the postpartum period. Maternity nursing skills should be recognized as a fundamental part of generalist rural nursing skills. 8. Remuneration for maternity care providers should reflect the unique challenges and increased professional responsibility faced by providers in rural settings. Remuneration models should facilitate interprofessional collaboration. 9. Practitioners skilled in neonatal resuscitation and newborn care are essential to rural maternity care. 10. Training of rural maternity health care providers should include collaborative practice as well as the necessary clinical skills and competencies. Sites must be developed and supported to train midwives, nurses, and physicians and provide them with the skills necessary for rural maternity care. Training in rural and northern settings must be supported. 11. Generalist skills in maternity care, surgery, and anaesthesia are valued and should be supported in training programs in family medicine, surgery, and anaesthesia as well as nursing and midwifery. 12. All physicians and nurses should be exposed to maternity care in their training, and basic competencies should be met. 13. Quality improvement and outcome monitoring should be integral to all maternity care systems. 14. Support must be provided for ongoing, collaborative, interprofessional, and locally provided continuing education and patient safety programs.

[Desmoid tumour around the DIEP anastomosis - a rare complication after breast reconstruction]

Abdominal desmoid tumors are so called non-metastatic tumors. They occur by proliferation of fibroblasts of muscle, fascia or aponeuroses. After breast reconstruction with a DIEP flap (Deep Inferior epigastric Artery Perforator Flap), a progressive growth of a desmoid tumor was seen around the DIEP-anastomosis. A total excision was not possible without compromising the vascular pedicle. With taking into account a recurrence rate up to 65% another operation is probably necessary. In this case the main vessels of the graft have to be cut out and a necrosis of the flap can or may appear.

Rural health services: finding the light at the end of the tunnel

Many rural communities across canada are facing challenges to the sustainability of core emergency and acute care health services, primarily due to problems with medical and nursing staffing. Data related to service efficacy and effectiveness are not well organized. Most of Canada still relies on reporting by large geopolitical areas (local health areas) that do not always relate natural catchment population outcomes to community hospital services. Re-organizing rural health services' outcome reporting by the characteristics of geographically defined catchment populations would facilitate better planning, systemic quality improvement and stronger continuing professional development for health professionals. It may also serve to inform the transformation of core health services in larger communities.

The outcomes of perinatal surgical services in rural British Columbia: a population-based study

INTRODUCTION

A substantial number of small surgical services in rural Canada have been discontinued in the past 15 years because of difficulties recruiting and retaining practitioners, health care restructuring and a lack of a coherent evidence base regarding the safety of small services. The objective of this study was to examine the safety of small perinatal surgical services.

METHODS

We accessed perinatal data for singleton births that occurred in British Columbia between Apr. 1, 2000, and Mar. 31, 2007. We defined hospital service levels, population catchment areas surrounding each hospital and the postal codes linked to those catchment areas. Births were linked with specific catchment areas and amalgamated by service level. We made comparisons among service strata populations and adjusted for potentially confounding characteristics.

RESULTS

A total of 87 294 births occurred during the study period. The births were distributed across 6 strata of services, which ranged from no local maternity services to services supported by obstetricians. Fifteen catchment areas were served by general practitioners with enhanced surgical skills (GPESSs), and 9174 births were included from this obstetric service level. Outcomes for surgical services provided by GPs compared favourably to those provided by obstetricians.

CONCLUSION

Our results suggest that small surgical services supported by GPESSs are a safe health services model to meet the needs of rural women and families.

Cultures of risk and their influence on birth in rural British Columbia

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.

GP Surgeons' Experiences of Training in British Columbia and Alberta: A Case Study of Enhanced Skills for Rural Primary Care providers

INTRODUCTION

There has been a steady erosion of family physicians with enhanced surgical skills providing care for rural residents. This has been largely due to the lack of formal training avenues and continuing medical education (CME) opportunities afforded to those interested, and attrition of those currently practicing.

METHODS

A qualitative study was undertaken using an exploratory policy framework to guide the collection of in-depth interview data on GP surgeons' training experiences. A purposive sample of GP surgeons currently practicing in rural BC and Alberta communities yielded interviews with 62 participants in person and an additional 8 by telephone. Interviews were audio recorded and transcribed then subjected to a process analysis.

RESULTS

Participants thematically identified motivations for acquiring advanced skills training, resources required (primarily in the area of solid mentorship), the most efficacious context for a training program (structured), and differences in mentorship between obstetricians and general surgeons.

CONCLUSION

Mentors and role models were the most salient influencing factor in the trajectory of training for the participants in this study. Mentorship between specialists and generalists was constrained at times by inter-professional tensions and was accomplished more successfully within a curriculum-based, structured environment as opposed to a learner-responsive training environment.

Distance matters: a population based study examining access to maternity services for rural women

BACKGROUND

In the past fifteen years there has been a wave of closures of small maternity services in Canada and other developed nations which results in the need for rural parturient women to travel to access care. The purpose of our study is to systematically document newborn and maternal outcomes as they relate to distance to travel to access the nearest maternity services with Cesarean section capability.

METHODS

Study population is all women carrying a singleton pregnancy beyond 20 weeks and delivering between April 1, 2000 and March 31, 2004 and residing outside of the core urban areas of British Columbia. Maternal and newborn data was linked to specific geographic catchments by the B.C. prenatal Health Program. Catchments were stratified by distance to nearest maternity service with Cesarean section capability if greater than 1 hour travel time or level of local service. Hierarchical logistic regression was used to test predictors of adverse newborn and maternal outcomes.

RESULTS

49,402 cases of women and newborns resident in rural catchments were included. Adjusted odds ratios for prenatal mortality for newborns from catchments greater than 4 hours from services was 3.17 (95% CI 1.45-6.95). Newborns from catchments 2 to 4 hours, and 1 to 2 hours from services generated rates of 179 and 100 NICU 3 days per thousand births respectively compared to 42 days for newborns from catchments served by specialists.

CONCLUSIONS

Distance matters: rural parturient women who have to travel to access maternity services have increased rates of adverse prenatal outcomes.

Development and Psychometric Testing of the Rural Pregnancy Experience Scale (RPES)

Rural pregnant woman who lack local access to maternity care due to their remote living circumstances may experience stress and anxiety related to pregnancy and parturition. The Rural Pregnancy Experience Scale (RPES) was designed to assess the unique worry and concerns reflective of the stress and anxiety of rural pregnant women related to pregnancy and parturition. The items of the scale were designed based on the results of a qualitative study of the experiences of pregnant rural women, thereby building a priori content validity into the measure. The relevancy content validity index (CVI) for this instrument was 1.0 and the clarity CVI was .91, as rated by maternity care specialists. A field test of the RPES with 187 pregnant rural women from British Columbia indicated that it had two factors: financial worries and worries/concerns about maternity care services, which were consistent with the conceptual base of the tool. Cronbach’s alpha for the total RPES was .91; for the financial worries subscale and the worries/concerns about maternity care services subscale, alpha were .89 and .88, respectively. Construct validity was supported by significant correlations between the total scores of the RPES and the Depression Anxiety Stress Scales (DASS [r =.39, p < .01]), and subscale scores on the RPES were significantly correlated and converged with the depression, anxiety, and stress subscales of the DASS supporting convergent validity (correlations ranged between .20; p < .05 and .43; p < .01). Construct validity was also supported by findings that the level of access and availability of maternity care services were significantly associated with RPES scores. It was concluded that the RPES is a reliable and valid measure of worries and concerns reflective of rural pregnant women’s stress and anxiety related to pregnancy and parturition.

The Reality of Resistance: The Experiences of Rural Parturient Women

The closure of many local maternity services has given rise to contemporary realities of care for many rural parturient women in Canada, which, in turn, determines their experience of birth. To date, we do not have an understanding of the realities influencing the birthing experiences of rural parturient women. This qualitative investigation explored these issues with women from four rural British Columbian communities through semistructured interviews and focus groups. Women in this study articulated four realities that influenced the nature of their experience of birth, including geographic realities, the availability of local health service resources, and the influence of parity and financial implications of leaving the community to give birth. When these realities were incongruent with participants' needs in birth, participants developed strategies of resistance to mitigate the dissonance. Strategies included trying to time the birth at the referral hospital by undergoing an elective induction and seasonal timing of pregnancies to minimize the risk of winter travel. Some women showed up at the local hospital in an advanced stage of labor to avoid transfer to a referral center, or in some instances, had an unassisted homebirth.

Planning the optimal level of local maternity service for small rural communities: a systems study in British Columbia

OBJECTIVES

To develop and apply a population isolation model to define the appropriate level of maternity service for rural communities in British Columbia, Canada.

METHODS

Iterative, mathematical model development supported by extensive multi-methods research in 23 rural and isolated communities in British Columbia, Canada, which were selected for representative variance in population demographics and isolation. Main outcome measure was the Rural Birth Index (RBI) score for 42 communities in rural British Columbia.

RESULTS

In rural communities with 1h catchment populations of under 25,000 the RBI score matched the existing level of service in 33 of 42 (79%) communities. Inappropriate service for the rural population was postulated and supported by qualitative data available on 6 of the remaining 9 communities.

CONCLUSIONS

The RBI is a potentially pragmatic tool in British Columbia to help policy makers define the appropriate level of maternity service for a given rural population. The conceptual structure of the model has broad applicability to health service planning problems in other jurisdictions.

Does distance matter? Increased induction rates for rural women who have to travel for intrapartum care

OBJECTIVES

Although there has been a devolution of local rural maternity services across Canada in the past 10 years in favour of regional centralization, little is known about the health outcomes of women who must travel for care. The objective of this study was to compare intervention rates and outcomes between women who live adjacent to maternity service with specialist (surgical) services and women who have to travel for this care.

METHODS

The BC Perinatal Database Registry provided data for maternal and newborn outcomes by delivery hospital for 14 referral hospitals (selected across a range of 250-2500 annual deliveries) between 2000 and 2004. Three hospitals were selected for sub-analysis on the basis of almost complete capture of the satellite community population (greater than 90%) to avoid referral bias.

RESULTS

Women from outside the hospital local health area (LHA) had an increased rate of induction of labour compared with women who lived within the hospital LHA. Sub-analysis by parity demonstrated that multiparous women had increased rates of induction for logistical reasons.

CONCLUSION

Rural parturient women who have to travel for care are 1.3 times more likely to undergo induction of labour than women who do not have to travel. Further research is required to determine why this is the case. If it is a strategy to mitigate stress incurred due to separation from home and community, either a clinical protocol to support geographic inductions or an alternative strategy to mitigate stress is needed.

Rural maternity care services under stress: the experiences of providers

INTRODUCTION

Between 2000 and 2004, 17 small rural maternity care services in British Columbia (BC) closed or were placed under moratoria. This paper explores the experiences of care providers in 4 rural BC communities that have lost or are at risk of losing their local maternity services.

METHODS

We conducted qualitative, semistructured interviews and focus groups with 27 health care providers (doctors and nurses) and 3 administrators. The analysis used modified grounded theory. We chose 4 rural communities to include a diversity of characteristics, including community size, geography, distance to the nearest hospital capable of performing cesarean section, and cultural and ethnic subpopulations.

RESULTS

Care providers identified significant stressors related to the provision of maternity care services, including the development and maintenance of competency in the context of decreasing birth volume, the safety of local maternity care without cesarean section and the desire to balance women's needs with the realities of rural practice.

CONCLUSIONS

Maternity care providers in small rural communities are experiencing stress due in part to the absence of evidence-based policy and planning for rural maternity care services. This stress may contribute to challenges in the retention of rural maternity care providers, thus risking the future of small rural maternity services.

Eine mikroangiographische Technik zur Quantifizierung fasziokutaner Blutgefäße am kleinen Versuchstier

PURPOSE

A microangiographic technique is described, which allows visualization of small blood vessels with a diameter of approximately 20 microm and quantification of fasciocutaneous blood vessels by means of digital computer analysis in very small laboratory animals.

METHOD

The left carotid artery of 45 nu/nu mice was cannulated (26 gauge) and a mixture of gelatine, barium sulfate and green ink was injected according to standardized protocol. Fasciocutaneous blood vessels were visualized by digital mammography and analyzed for vessel length and vessel surface area as standardized units (pixel) by computer program.

RESULTS

With the described microangiography method fasciocutaneous blood vessels can be clearly visualized. Regions of interest (ROIs) can be defined and the containing vascular network quantified. Identical ROIs showed a high reproducibility for measured unit (pixel) < 6.5 +/- 2.4 %. By the use of digital image, processing the quantification of vessels was reliable, reproducible and fast.

CONCLUSION

Combining microsurgical techniques, pharmacological knowledge and modern computer imaging analysis systems, we were able to visualize and quantify blood vessels with a diameter of approximately 20 microm even in small laboratory animals.

A technique to detect and to quantify fasciocutaneous blood vessels in small laboratory animals ex vivo

PURPOSE

A microangiographical technique is described, which allows visualization of small and capillary blood vessels and quantification of fasciocutaneous blood vessels by means of digital computer analysis in very small laboratory animals.

MATERIALS AND METHODS

The left carotid artery of 20 nu/nu mice was cannulated (26 gauge) and a mixture of gelatin, bariumsulfate, and green ink was injected according to standardized protocol. Fasciocutaneous blood vessels were visualized by digital mammography and analyzed for vessel length and vessel surface area as standardized units [SU] by computer program.

RESULTS

With the described microangiography method, fasciocutaneous blood vessels down to capillary size level can be clearly visualized. Regions of interest (ROIs) can be defined and the containing vascular network quantified. Comparable results may be obtained by calculating the microvascular area index (MAI) and the microvascular length index (MLI), related to the ROIs size. Identical ROIs showed a high reproducibility for measured [SU] < 0.01 +/- 0.0012%.

CONCLUSION

Combining microsurgical techniques, pharmacological knowledge, and modern digital image technology, we were able to visualize small and capillary blood vessels even in small laboratory animals. By using our own computer analytical program, quantification of vessels was reliable, highly reproducible, and fast.

Does having cesarean section capability make a difference to a small rural maternity service?

OBJECTIVE

To determine whether having cesarean section capability in an isolated rural community makes a difference in adverse maternal or perinatal outcomes.

DESIGN

Retrospective study comparing population-based obstetric outcomes of two rural remote hospitals in northwestern British Columbia. One hospital had cesarean section capability; one did not.

SETTING

Bella Coola General Hospital (with cesarean section capability) in Bella Coola Valley (BCV) and Queen Charlotte Islands General Hospital (without cesarean section capability) in Queen Charlotte City (QCC).

PARTICIPANTS

Women who carried pregnancies beyond 20 weeks' gestation and who gave birth between January 1, 1986, and December 31, 2000.

INTERVENTIONS

British Columbia Vital Statistics Agency data was used to compare obstetric outcomes in the two communities. A chart audit of local births at BCV and QCC was done to validate the vital statistics data.

MAIN OUTCOME MEASURES

Perinatal death, newborn transfer to a tertiary care facility, birth weight, gestational age at delivery, mode of delivery, and Apgar score.

RESULTS

The rate of preterm deliveries in QCC was higher (relative risk 1.41, 95% confidence interval 1.00 to 1.99; P = .047) than the rate in BCV. Otherwise, there were no differences in adverse maternal or perinatal outcomes in the two populations. In BCV, 69.8% of women delivered locally compared with 50.2% of women in the southern Queen Charlotte Islands (P < .001).

CONCLUSION

Having local cesarean section capability is associated with a greater proportion of local deliveries and a lower rate of preterm deliveries.

Safety and Community: The Maternity Care Needs of Rural Parturient Women

OBJECTIVE

To investigate rural parturient women's experiences of obstetric care in the context of the social and economic realities of life in rural, remote, and small urban communities.

METHODS

Data collection for this exploratory qualitative study was carried out in 7 rural communities chosen to represent diversity of size, distance to hospital with Caesarean section capability and distance to secondary hospital, usual conditions for transport and access, and cultural and ethnic subpopulations. We interviewed 44 women who had given birth up to 24 months before the study began.

RESULTS

When asked about their experiences of giving birth in rural communities, many participants spoke of unmet needs and their associated anxieties. Self-identified needs were largely congruent with the deficit categories of Maslow's hierarchy of needs, which recognizes the contingency and interdependence of physiological needs, the need for safety and security, the need for community and belonging, self-esteem needs, and the need for self-actualization. For many women, community was critical to meeting psychosocial needs, and women from communities that currently have (or have recently had) access to local maternity care said that being able to give birth in their own community or in a nearby community was necessary if their obstetric needs were to be met.

CONCLUSION

Removing maternity care from a community creates significant psychosocial consequences that are imperfectly understood but that probably have physiological implications for women, babies, and families. Further research into rural women's maternity care that considers the loss of local maternity care from multiple perspectives is needed.

Evidence-based prenatal care: part II. Third-trimester care and prevention of infectious diseases

All pregnant women should be offered screening for asymptomatic bacteriuria, syphilis, rubella, and hepatitis B and human immunodeficiency virus infection early in pregnancy. Women at increased risk should be tested for hepatitis C infection, gonorrhea, and chlamydia. All women should be questioned about their history of chickenpox and genital or orolabial herpes. Routine screening for bacterial vaginosis is not recommended. Influenza vaccination is recommended in women who will be in their second or third trimester of pregnancy during flu season. Women should be offered vaginorectal culture screening for group B streptococcal infection at 35 to 37 weeks' gestation. Colonized women and women with a history of group B streptococcal bacteriuria should be offered intrapartum intravenous antibiotics. Screening for gestational diabetes remains controversial. Women should be offered labor induction after 41 weeks' gestation.

Is Local Maternity Care an Optional Service in Rural Communities?

There has been a precipitous decline in the number of rural communities across Canada providing local maternity care. The evidence suggests that the outcome for newborns may be worse as a result. There is also an emerging understanding of the significant physiological and psychosocial consequences for rural parturient women. Because they cannot plan for birth with any certainty, many of them experience labour and delivery in referral communities as a crisis event fraught with anxiety. The literature suggests that, within a regionalized perinatal system, small maternity services can offer safe care provided that an efficient mechanism for intrapartum transfer has been established. This commentary provides recommendations for sustainable maternity care that will meet the needs of women, their families, and maternity caregivers in rural communities. The recommendations stem from a rural maternity care program of research, consultations with communities, and review of relevant epidemiologic and policy literature.