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Cultures of risk and their influence on birth in rural British Columbia Kornelsen, Jude; Grzybowski, Stefan Nov 16, 2012

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RESEARCH ARTICLE Open AccessCultures of risk and their influence on birth inrural British ColumbiaJude Kornelsen*† and Stefan Grzybowski†AbstractBackground: A significant number of Canadian rural communities offer local maternity services in the absence ofcaesarean section back-up to parturient residents. These communities are witnessing a high outflow of womenleaving to give birth in larger centres to ensure immediate access to the procedure. A minority of women chooseto stay in their home communities to give birth in the absence of such access. In this instance, decision-makingcriteria and conceptions of risk between physicians and parturient women may not align due to the privileging ofdifferent risk factors.Methods: In-depth qualitative interviews and focus groups with 27 care providers and 43 women from 3 ruralcommunities in B.C.Results: When birth was planned locally, physicians expressed an awareness and acceptance of the clinical riskincurred. Likewise, when birth was planned outside the local community, most parturient women expressed anawareness 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. Assuch, an awareness can address the impasse and work to provide a resolution to the competing prioritizations ofrisk.Keywords: Access to care, Rural and remote, Maternity care, Canada, Risk perceptionBackgroundThere has been a sudden decline in the number of ruralcommunities across Canada offering local maternity caresince 2000 [1-3] due to a confluence of factors includingthe regionalization of health services delivery in manyjurisdictions [4], physician recruitment and retentionchallenges [5], limited access to midwives [6,7], anddiminished access to nurses trained in obstetrics [8]. Asignificant number of communities that continue tooffer local maternity services to parturient residents inthe absence of surgical back-up are witnessing a highoutflow of women leaving to give birth in larger centresin order to ensure immediate access to caesarean sectioncapabilities. This type of outflow is not unique toCanada and has also been observed in other medicallyadvanced countries such as the United States and theUnited Kingdom [9,10]. A minority of women fromthese communities choose to stay in their home com-munities to give birth [11].An overview of the rural maternity care research lit-erature suggests that the onus has been to prove thesafety of small rural maternity care services in the faceof assumptions that they were less safe than centralized,specialized service units. Most studies focusing on thesafety of rural maternity care services have used peri-natal mortality rates and birth weight-specific perinatalmortality rates as the key outcome measure [12]. Bycomparing Level I (general practitioners only) facilities’birth outcomes with those of Level II (regional referralhospital staffed by specialist obstetricians) and Level III(highly-specialized obstetric and neonatal care) facilities,researchers have sought to uncover whether or not LevelI services are equally or less safe than more specializedobstetric centres [13-26]. When taken together, the evi-dence from this body of research supports the assertionthat “‘safety cannot be used as a basis for centralizingbirth care in large Level III facilities” [27]. Furthermore,* Correspondence: jude.kornelsen@familymed.ubc.ca†Equal contributorsCentre for Rural Health Research, Department of Family Practice, University ofBritish Columbia, Vancouver, Canada© 2012 Kornelsen and Grzybowski; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms ofthe Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Kornelsen and Grzybowski BMC Family Practice 2012, 13:108http://www.biomedcentral.com/1471-2296/13/108the question of whether or not rural maternity care ser-vices require caesarean section capabilities is not defini-tively addressed in the literature, despite the number ofrural obstetric units that, historically, have operatedwithout local surgical backup [13,16,26-28].Most importantly, the literature has not systematicallyexplored the implications of no local access to maternityservices in rural communities. In a pioneering study,Larimore and Davis showed that in rural Florida coun-ties there was a negative correlation between availabilityof maternity care services and infant mortality (R = -0.42,P = .012) [29]. Among the speculated negative socialconsequences of losing local maternity care services arethe potentially harmful stressors associated with preg-nant women traveling for perinatal care [2,30]. Theimplications of barriers to access to local care are exa-cerbated for populations with less material and socialresources [31,32].The decision to offer local maternity services in theabsence of caesarean section capability is a complex onerequiring the alignment of administrators and care pro-viders, the support of health authorities, and theexpressed desire of community members within a realis-tic understanding of risks incurred. Beyond these struc-tural influences, individual practitioners must assess thecandidacy of each individual woman who wishes to stayin the community. This is usually done within a contextof risk assessment. Contemporary risk assessment com-bines the clinical judgement of care providers with pol-icy guidelines and standardized risk assessment indices[33,34]. As perinatal services have been regionalized,standardized risk-scoring systems have become increas-ingly popular as a way to identify ‘high-risk’ pregnanciesthat need the services found in larger, regional centres[33,35,36], despite challenges to the accuracy and effi-cacy of such indices [37-39]. At issue, however, is theprivileging of quantifiable measures to the exclusion ofthose unquantifiable factors that have profound influ-ence on the nature of pregnancy, labour, and delivery[33,34,40]. It has further been suggested that the exces-sive reliance on risk assessment tools may give rise to areductionist view of pregnancy and birth as a biomedicalevent as opposed to a holistic and integrated life process[34,39,41].The decision of whether a woman stays in her localcommunity to birth or leaves prior to the onset of labourto birth in a referral facility is not made by the care pro-vider alone, but in ideal situations is a product of aprocess of shared decision-making between a care pro-vider and patient. As argued by Mackenzie-Bryers andTeijlingen, a shared decision making model allows theexperiences of the patient to be incorporated into thedecision-making process [10]. To date, while it is beingacknowledged that there are differing views of whatconstitutes risk between clinicians and parturientwomen [10,42], there remains a need to understandwhat factors rural parturient women weigh when asses-sing risk. Particular attention needs to be paid towhether or not women’s views reconcile with care provi-ders’ priorities. This exploratory, qualitative investigationsought to answer the question, “What are the maternitycare experiences of rural care providers and parturientwomen including their perspectives on risk?” We willconsider rural women and care providers’ perspectiveson risk, acknowledging the frequent eclipse of one bythe other due to the lack of understanding of eachother’s priorities.MethodsOpen-ended interviews and focus groups were under-taken in three rural communities in British Columbiachosen to represent diversity in population ethnicity andculture, geography (including distance to referral centrewith caesarean section capability), and usual weatherconditions (see Table 1). All primary care providers inthe three communities were recruited by mail andfollow-up phone calls to participate in interviews;women were recruited using a third-party recruitmentprocess through local public health nurses and throughthe “snowball technique.” Inclusion criteria for womenincluded being a resident of the study community andhaving given birth in the past 2 years. Care providerswere required to be practicing and living in the studycommunity and to be offering maternity care as part ofthe practice.Interviews were conducted by the co-investigators (JK,SG) and assisted by a research coordinator and two re-search assistants. The co-investigators are a health ser-vices researcher (JK), who has studied the socialdimensions of childbirth, and family physician researcher(SG), who worked as a rural family physician providingmaternity care in an isolated rural community for11 years. In each interview, one team member con-ducted the interview and one member took notes. Eachinterview lasted between 30 and 90 minutes and tookplace in the participant’s home community in a locationdetermined by the participant (primarily in a local healthcentre, hospital, or coffee shop). All interviews wereaudio recorded with the participants’ permission andtranscribed.Thematic analysis of transcripts and field notes wasundertaken by the co-investigators and the research co-ordinator through the following steps: (1) transcriptsand field notes were read and re-read until team mem-bers had a thorough understanding of the data; (2) initialcoding for themes was undertaken independently oneight transcripts and independent code books were con-structed by one of the co-investigators (JK) and theKornelsen and Grzybowski BMC Family Practice 2012, 13:108 Page 2 of 7http://www.biomedcentral.com/1471-2296/13/108research coordinator; (3) code books were compared todetermine level of congruence; (4) a composite codebook was created by one of the co-investigators (JK) toguide coding of the complete data. The primary frame-work for analysis was a logic model framework includingarticulation of activities, resources, outcomes, outputs,and impacts. A secondary, open analysis of the data wasundertaken by the co-investigators and yielded thethemes of safety and risk [43,44]. Preliminary findingswere presented to participants and other members ofthe communities, and participants expressed a high levelof resonance between the findings and their experiences.This paper will focus on the theme of risk and safety.Ethical approval for this research was sought andreceived from the University of British Columbia’s Be-havioural Research Ethics Board.ResultsInterviews were conducted with a total of 27 care provi-ders and 43 women (9 of whom gave birth in their homecommunity and 34 of whom delivered away). The careproviders included general practitioners (GPs), labour anddelivery nurses, operating room nurses, one GP Surgeon,and one GP Anaesthetist. In the community with the GPSurgical service, local caesarean section back up was avail-able only intermittently. The annual number of deliveriesfor each community was small, with fewer than 35 annualbirths in each community to women living within onehour of the local hospital. In all three communities, in-cluding the community with a GP Surgical service, therewas a high outflow of birthing women to referral centresfor labour and delivery services.Perspectives on risks differed between physicians andbirthing women: the immediacy of the stress associatedwith risk depended on the place of birth. When birthtook place in the home community, nurses and physi-cians expressed an awareness of clinical concerns aboutthe management of labour, and fears about the potentialfor a bad outcome. When birth was away, womenexpressed their experience of the significant anxiety thatsocial stressors cause, due to separation from family andcommunity. These disparate concerns reflected partici-pants’ underlying values (see Table 2).Clinical riskAll care providers in this study expressed a high level ofawareness of the clinical risks involved in offering mater-nity care in communities without local surgical back-up,underscored by an acknowledgment of the unpredict-ability of birth. These risks were perceived to increasewith a problematic reproductive history, compromisedhealth or social status, and by parity, with nulliparouswomen being perceived to have the highest risk. Wea-ther concerns, leading to challenges in transport out ofthe community, accentuated perceptions of clinical riskfor almost all providers.Care providers also expressed an awareness of theclinical risks involved in an unplanned precipitous deliv-ery in the community. This might occur due to the onsetof labour prior to the time of relocation to the referralcommunity, or the “10 cm strategy,” which indicates thata woman who is dilated 10 cm or more can no longer bebe safely transferred [45]. This led to strategies tominimize the potential for “high risk” women going intolabour in the communities. Strategies include developingan awareness of risk factors for preterm labour and asense of acuity in predicting who may either elect to staybeyond the recommended time or who may travel to theTable 1 Community backgroundCommunity 1 Community 2 Community 3Yearly Weather Conditionsa Temp (Summer): 5° to 20°C Temp (Summer): 18°C Temp (Summer): 19°CTemp (Winter): 5° to -15°C Temp (Winter): 4°C Temp (Winter): 2°CPrecipitation:2500 mm Precipitation: 7559 mm Precipitation: 6284 mmSnowfall: High levels in the winter months Snow: Rare Snow: Occasional snowfall inwinter monthsTravel DistanceTime to Referral Centreb452 km 203 km 298 km6 h travel over land 5 h travel via car and ferry 7 h travel via car and ferryDemographicsc Population: 135 Population: 1045 Population: 940Catchment: 2897 Catchment: 3000 Catchment: 250050% Aboriginal 37% Aboriginal 37% AboriginalSource: Data adapted from http://rccbc.ca.Notes:a“Temp” refers to the average seasonal temperature. “Precipitation” represents the annual average rainfall in the community.bTravel time reflects the average length of time during optimal weather conditions that it takes to access the nearest designated labour and delivery service withcaesarean section back-up.c“Catchment” refers to the population living within one-hour travel time of the local hospital. This includes people who live in smaller, surrounding communities.“Aboriginal” people are the original peoples of Canada and include First Nations, Inuit, and Metis groups. We have included the percentage of Aboriginal peopleliving in the one-hour catchment.Kornelsen and Grzybowski BMC Family Practice 2012, 13:108 Page 3 of 7http://www.biomedcentral.com/1471-2296/13/108referral community for a short time but return beforethe birth.Additionally, care providers also recognized their ownpersonal social risks of practicing within a low-technology context which included the social stigma inthe case of a bad outcome. This was predicated on theirexperiences of the integrated, multiple relationships inrural communities and the wide web of associational tiesthey had with community members. Several participantssaid that this vulnerability could be mitigated by a com-munity process that demonstrated a realistic understand-ing of the risks of local care without surgical back-up anda willingness to accept these risks.Social riskFor women who chose to deliver in a referral centre, so-cial risks were paramount and included: leaving familiesand support systems behind, the lack of continuity ofcaregiver, loss of positive attributes of birthing in thecommunity, and financial challenges incurred by leaving.Leaving families and support systems, and the lack of so-cial support this engendered were highlighted by almostall of the participants. For those who were able to accessprenatal care in their community, leaving the commu-nity also meant a disruption in their relationship withtheir care provider. The realities of financial stressorswere also perceived as a risk to leaving the community,particularly in instances when the additional costs oftravel and accommodation were prohibitive for theevacuating family.Many of the participants, particularly Aboriginalwomen, acknowledged the cultural risk to birthing out-side the community and a perceived illogic to the pre-cipitous change in historical practices. Several spoke ofthe sadness in not having their community name ontheir child’s birth certificate and others recalled the longhistory of practice of birth in the community.Participants in this study revealed thematically con-sistent ways in which they mitigated their perceivedrisks of leaving the community. One common responsewas to secure social support in the referral community,either by bringing family and friends or selecting a com-munity in which to birth based on the presence of anexisting support network (usually extended family). TheTable 2 Women and care providers’ views on social and clinical riskClinical Risk of Staying “It is more stressful with primips. And I’ve been in the plane withtwo or in the helicopter overnight with two primips in the past coupleof years going [to the referral community] in labour [with] stuckbabies and you know it’s, it is stressful and eventually I can see . . . itleading to me being a lot more reluctant.” (Care Provider 1, Community 1)“Yeah and now it’s like you know they send people off regardlessand at one time I had kind of a negative attitude about that but afterhaving seen [it] you never know when things could go really, really,really wrong and when people are stranded here with the weather.Like, there are lots of times when nothing moves. And yeah like itwould be really wonderful if everybody could have their babies athome or in the hospital here but as far as safety goes, I’m not sure ifthat’s really an option.” (Care Provider 1, Community 1)Social Risk of Leaving “I would just sort of like to not even think about leaving and just[stay] at home. I would almost rather risk that kind of a trip than haveto be away from home for so long.” (Participant 12, Community 2)“[When] you have the same doctor they know what’s going on withyour body . . . I think it would . . . be very uncomfortable for a firsttime mum to have to have seven different doctors.” (Participant 1,Community 3)“And it’s the poorer women that sort of suffer the most. Because youknow then they’re having to make the choice to stay up here. Wellit’s not a choice for them. They’re having to stay up here and then,you know, having to risk the mad dash [out of the community] justbecause they don’t have the money to stay there. And they’re awayfrom all their support.” (Participant 12, Community 2)“Cause I’m a single mother and I’ve got four kids, I mean that’s ascary thing for me, and then I had to get respite set up in case I wentinto the hospital and I didn’t have anybody around and that was ascary thought too because then that’s getting the Ministry involved.”(Participant 7, Community 3)“We were having children in our homes [and] we were havingchildren naturally long before doctors came to be. We were havingchildren just the way I had my child eight months ago.”(Participant 6, Community 2)Kornelsen and Grzybowski BMC Family Practice 2012, 13:108 Page 4 of 7http://www.biomedcentral.com/1471-2296/13/108importance of securing access to additional financialsupport was also noted, primarily by Aboriginal women,who had access to funding through their bands fortravel, accommodation, and, in some instances, escortaccompaniment to the referral community. Othersnoted additional support sought through the appropri-ate government agencies, although not without concernabout the implications of engaging in ‘the system.’Discussion and conclusionsThe question of “risk” in medicine has traditionally priori-tized a clinical perspective as defined by care providers.This approach has excluded adequate consideration ofthe psycho-social influences that have a substantial im-pact on patients’ decision-making processes and disre-gards our growing understanding of health as a state ofphysical, mental, and social well-being [43]. Not surpris-ingly, care providers and patients may value differentcomponents of health, which will give rise to differentinterpretations of risk. This is acutely evident in maternitycare where there is continued dissonance in attitudes to-ward interventions in birth [46,47] and protocols such asinduction for post-dates pregnancies [47]. In a rural envir-onment with limited access to caesarean section services,the different values placed on the physical/mental/socialdimensions of health have frequently led to a privilegingof the medically defined course of care. Women in thisstudy identified social priorities in their decision for loca-tion of birth that were not adequately addressed by careproviders. The implications of this are significant and canlead to an antagonistic relationship where neither the careprovider nor woman feels heard. This can result in careproviders viewing parturient women as non-compliantand women feeling abandoned, and ultimately manifestsin increasingly stringent definitions of “high risk” preg-nancy and inappropriate referral out of the community.In extreme circumstances, women may choose unassistedhome births or arrive at a local hospital in advancedlabour to preclude transfer to a referral community. Par-turient women who engage in such activities to mitigatethe social risks of leaving their community face increasedclinical risks leading to potentially adverse outcomes.Findings from Grzybowski, Stoll, and Kornelsen indicatethat women who live 1-2 hours away from labour and de-livery services have an increased risk of an unplannedout-of-hospital delivery [48]. This study also illustratesthat women who live 2–4 hours from services haveincreased rates of intervention including the highest ratesof induction of labour for logistical reasons (i.e. to elec-tively induce labour so that they may return to theirhome community sooner). Further, newborns of motherswho live more than 4 hours from services are atincreased risk of perinatal mortality (adjusted OR 3.17,95% CI 1.45–6.95) [48]. Ironically, providers tend tointerpret the potential for adverse outcomes as cause forencouraging women to deliver in referral and tertiarycommunities, a strategy that may increase the socialstress women experience and be associated with thecomplications that care providers are trying to avoid.Conversely, if birthing women remain in the community,rural care providers may incur stress due to the uncer-tainty of providing intrapartum care and the potential forcommunity backlash if a bad clinical outcome occurs.The social risks for these practitioners can be significantenough for some to choose to cease providing intrapar-tum care or leave their community altogether [49].Ultimately, the concept of risk is applied to minimizeadverse outcomes for a population [50]. For rural par-turient populations, there are crucial nuances to ourunderstanding of risk that include parity, degree of isola-tion, and vulnerability of the population. For instance, innulliparous pregnancies where there is a heightened riskfor surgical intervention in comparison to multiparouspregnancies, care providers can be uncomfortable offer-ing local delivery and encourage nulliparous women todeliver away from their home community. Multiparouspatients, on the other hand, have potentially higher so-cial risks, as the responsibility of caring for their previ-ous children compounds the complexity and costs ofdelivering away. Multiparous patients are also at higherrisk of precipitate delivery (low risk for delivery locallybut at high risk for delivery en route if delivering awayand traveling in early labour) [51]. Geographic isolationis a key consideration in any decision surrounding arural woman’s planned birth. Is weather a factor? Whatare the risks of delivery en route if traveling to a referralsite in early labour? What is the risk of intrapartumtransfer? Furthermore, the overall vulnerability of thepopulation needs to be considered. If aggregate socio-economic status, educational background, and healthstatus is low, how likely are ‘unexpected’ complications?How important are the mitigating influences of cultureand family?A balanced approach to risk management grounded ina comprehensive approach to health is a necessary steptowards better health services for rural parturientwomen and their babies. This approach will need toweigh the issues care providers and women consider intheir risk assessment strategies. An efficacious way to dothis may involve development and testing of risk discus-sion guides and decision-making tools. Such tools mayaugment the communicative process by making explicitthe values and concerns guiding each perspective.Limitations of studyThe relationship between geographic realities and accessto specialists in referral centres dominates the debate onsafety and risk in rural maternity care. Although selectionKornelsen and Grzybowski BMC Family Practice 2012, 13:108 Page 5 of 7http://www.biomedcentral.com/1471-2296/13/108criteria for community study sites included diversity ofgeographic circumstances, including distance and condi-tions of access to the nearest referral centre, the geo-graphic diversity of rural communities cannot berepresented by three study sites. Caution must thus beexercised in transferring findings to dissimilar geographiclocations.Although Aboriginal women were included in thisstudy, they were not specifically recruited nor was theresearch undertaken within any Aboriginal communi-ties. We recognized differences in experiences betweenAboriginal and non-Aboriginal participants early in thedata-gathering process, emanating from the strength ofkinship ties in many Aboriginal communities and thesubsequent importance of extended family duringlabour, delivery, and the postpartum period. Additionaldifferences included socially complex factors such as thelower age for childbearing for Aboriginal women inCanada [52], as well as higher rates of substance abuseand medical conditions that may complicate pregnancy[53-55]. These differences suggest that nuances ofexperiences may not be transferable to rural Aboriginalwomen’s experiences of birth. The need for research onthis particular demographic is being answered, as seenin the recent study published by Driscoll and Kelly [56].Competing interestsThe authors declare that they have no competing interests whereappropriate.Authors’ contributionsJK contributed to conceptualizing the study, implementation and dataanalysis and was the lead writer of the manuscript. SG contributed toconceptualizing the study, implementation and the writing of themanuscript. Both authors read and approved the final manuscript.AcknowledgmentsThe authors express their appreciation to the women and care providers ofrural BC who candidly shared their experiences of risk in the childbearingyear. Additionally, they thank the research support of Liz Cooper, ShelaghLevangie, and Evelyn Eng, editorial support provided by the Centre for RuralHealth Research, and funding from the Canadian Institutes of HealthResearch.Received: 5 December 2011 Accepted: 14 August 2012Published: 16 November 2012References1. Hutten-Czapski P: The State of Rural Health Care. Presentation to: TheStanding Senate Committee on Social Affairs, Science and Technology. Ottawa,Canada; 2001 May 31.2. Rourke JTB: Trends in small hospital obstetrical services in Ontario. CanFam Physician 1998, 44:2117–2124.3. Hutton-Czapski P: Decline of obstetrical services in northern Ontario. CanJ Rural Med 1999, 4(2):72–76.4. 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BMC Family Practice 201213:108.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitKornelsen and Grzybowski BMC Family Practice 2012, 13:108 Page 7 of 7http://www.biomedcentral.com/1471-2296/13/108


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