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The Costs of separation : the birth experiences of women in isolated and remote communities in British… Grzybowski, Stefan; Kornelsen, Jude, 1965- 2005

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VOLUME 24, NUMBER 1 75Cet article est le résultat d’une enquêtequalitative des expériences d’accouchéesdans les communautés éloignées de laColombie-Britannique. Les résultatsdonnent une plus haut taux de mortalitécausée par l’obligation pour les femmesde quitter leur communauté pouraccoucher.There has been a precipitous declineduring the past few years in thenumber of rural communities acrossCanada offering local maternity careservices (Hutton-Czapski 2001,2000; Rourke). There have been sev-eral contributors to this trend includ-ing health service delivery restructur-ing, difficulties in physician reten-tion and recruitment in rural com-munities (Statement of Maternity andNewborn Care in Canada), and thetrend towards the “medicalization”of childbirth in industrialized coun-tries (Wiegers). Communities thathave lost services now join other smallrural and remote communities where,due to health human resource capac-ity, geographic isolation, and econo-mies of scale, local birth has not beenpart of the health services infrastruc-ture for several decades. Pregnantwomen in these small communitiesface significant challenges to access-ing care, which in many instancesleads to stress and anxiety during thechildbearing year (Kornelsen andGrzybowski 2004b; Chamberlainand Barclay).The Costs of SeparationThere is a growing understandingof the physiological consequences ofstress during pregnancy, with researchfocusing primarily on the relation-ship between stress and preterm la-bour (Mackey and Boyle; Misra;Hedegaard et al. 1996; Cooper et al.;Wadhwa et al.; Mackey, Williamsand Tiller; Hedegaard et al. 1993)and, as K. Marieke Paarlberg et al.note, the role of psychosocial stressorsas determinants of obstetrical prob-lems.  Specific events correlated withstress include family disruption, apartner who is regularly absent, andfinancial insecurity due to job loss,transfer or no money at all(Moutquin), as well as the overallsocial or cultural context of a preg-nant woman (Moffitt). Carol Hogueet al. describe,Stressful life events have been de-fined as exposure to out-of-the-ordinary, demanding events …that have the capacity to changethe patterns of life or arouse veryunpleasant feelings.” (35)One such stressful life event forrural pregnant women is leaving theircommunity and family to give birth.This may be particularly relevant toAboriginal women, many of whomlive in small often marginalized com-munities in rural environments.Historically birth in Aboriginal com-munities was a community event andas such, strengthened ties within fami-lies and nations (Moffitt). More re-cently there has been a systematicevacuation of women due to shiftingpolicy and practice including immi-gration restrictions on foreign-trainednurse-midwives who traditionallystaffed remote outposts (Jasen). Theconsequences have been severe, lead-ing away from birth as a communityevent to birth as an isolating experi-ence resulting in feelings of loss ofcontrol for women (Jasen; Robinson;Voisey et al.). There are also implica-tions for the community. In describ-ing the Pauktuutit (Inuit Women’sAssociation) perspective, MarthaGreig notes that the loss of self-suffi-ciency and competency is felt by olderwomen as well, for those who acted asmidwives in the past believe theirown knowledge has been discred-ited, wasted, and ignored.When talking of their evacuationexperience, northern Aboriginalwomen themselves express regret atnot having family close by to sharetheir birthing experience and notethe difficulty for women to focus ongiving birth to a newborn when theyare anxious about being away fromtheir homes and children for extendedperiods of time (Paulette; Voisey etal.). In a comprehensive overview ofthe unintended consequences ofmaternal evacuation from the farnorth, Jennifer Stonier lists the detri-mental health effects on women (e.g.,JUDE KORNELSEN AND STEFAN GRZYBOWSKIThe Birth Experiences of Women in Isolatedand Remote Communities in British Columbia76 CANADIAN WOMAN STUDIES/LES CAHIERS DE LA FEMMEloneliness, worry, anxiety, loss of ap-petite, increased smoking behaviour)and those on the children and familyleft behind (increased rates of illnessand school problems for other chil-dren of evacuated women and theloss of understanding of the birthprocess among men). Stonier alsodescribes that with so much energy,time, and money devoted to the im-mediate intrapartum period, fewersocial and economic realities of life inrural, remote, and small urban com-munities. Data collection was carriedout in eleven rural and remote com-munities of mixed Aboriginal andnon-Aboriginal populations in Brit-ish Columbia chosen to representdiversity in cultural and ethnic sub-populations, size, geographic features,and distance to nearest hospital withcesarean section capability in usualhad given birth up to 24 monthsprior to the onset of the study andwhose primary residence during thistime was in one of the research com-munities. A total of eleven womenwere interviewed, all of whom gavebirth outside their community. Allinterviews except one were audio tape-recorded (one participant expresseda preference not to be recorded) andtranscribed. Extensive field notes werealso taken by both authors followingeach interview. Seven women in threecommunities were video-taped. Alldata is included in the analysis. Ethi-cal approval for the study was soughtand received from the appropriateBehavioural Research Ethics Board.Data AnalysisThe analysis was carried out in twophases using a modified approach togrounded theory which included theuse of traditional procedures such asthe coding of emerging data, the useof techniques for ongoing compara-tive analysis, making connectionsbetween themes and sub-themes andmemo writing as a form of reflexivity(Charmaz). In phase one, both au-thors independently coded the tran-scripts and field notes and identifiedemerging themes. Upon comparisonthere was a high degree of thematiccongruence between the independ-ent coding. Phase two involved col-laboratively articulating the meta-themes of separation, social disrup-tion and costs.Theoretical FrameworkThe narratives of participants inthis study were grounded in stories ofsocial disruption and separation andthe costs associated with such separa-tion. As experiences of stress andanxiety were common to many of thewomen we spoke with, the results areconsidered from within current lit-erature on psychosocial determinantsof stress in pregnancy.ResultsThe women in these communitiesare advised to travel to the referralresources were available for care andeducation services within the com-munity, contributing to the dimin-ishment of prenatal preparation andpostnatal support.Although the experiences ofwomen in the Canadian far northhave been well-documented (Cham-berlain and Barclay; Jasen; O’Neiland Gilbert), we do not have a clearunderstanding of the experiences ofwomen in remote or isolated com-munities in other parts of the countrywhere health services context, geog-raphy, and access to services maydiffer significantly from their farnorthern counterparts which tend tobe more isolated. This paper willconsider results from a qualitativestudy on remote and isolated ruralpregnant women’s experiences ofleaving their communities to givebirth. An understanding of women’sexperiences leads to a greater under-standing of the importance of at-tending to the psycho-social needs ofisolated and remote pregnant women,and their families.MethodsThe goal of this exploratory, quali-tative study was to investigate ruralpregnant women’s experiences ofobstetrical care in the context of theconditions of road and air access inwinter months. Three of the com-munities were very small, isolated,and remote (total population of thecommunities is under 1,000) andalthough they met access to servicesstandards set by provincial policydocuments (access to obstetrical serv-ices within four hours air travel[Mate]), they were over nine hoursfrom such services by car. Further-more, these communities had notsupported local birth for residents forover 30 years. We hypothesized thatthe longstanding lack of local serviceswould contribute important insightsto our program of research into theexperiences of women from ruralcommunities no longer able to accessservices in their home community.For this reason, transcripts wereanalyzed separately and resultsdisaggregated from the larger study.Data CollectionThe isolated and remote commu-nities were all primarily Aboriginalwith a small non-Aboriginal birthingpopulation. Permission was requestedby the research team from the Bandand Health Councils to undertakethe research within the communi-ties. Once permission was received,face-to-face unstructured interviewswere undertaken with women who“That was rough cause it was my first kid andstaying in a hotel, I didn’t like that. You had to stayin a hotel the whole time and you go there for awhole month before you have your baby.”VOLUME 24, NUMBER 1 77community where they will give birthat, or close to, 36 weeks gestation aslack of local maternity health servicesresourses precludes local birth. Wherepossible the women are accompa-nied by partners or family membersfor part of their stay in the referralcommunity (which may last up to sixweeks).Participants in this study conveyednarratives around their birthing ex-periences that were underscored bythe themes of separation at the time ofbirth and the social disruption andother costs associated with this sepa-ration. These themes emergedthrough the following discussions.Deciding on a ReferralCommunitySeveral factors came into play forparticipants when determining wherethey would give birth, including geo-graphic proximity, familiarity withthe community (“When we leave hereto go shopping people go to [com-munity] so it’s like, automatic to gothere. We know where everythingis.”), physician referral patterns, repu-tation of the community and, mostimportantly, the presence of familyand friends. Although the presenceof family and friends in the referalcommunity often mitigated the fi-nancial burden many of the partici-pants faced, it did not dminish theanxiety most participants felt beingaway from their home communityand their other children.Although most participantstraveled to the nearest referral com-munity for birth (nine hours by car)some traveled farther if they neededmore specialized care or chose torelocate to a larger community whereextended family or friends resided.These participants felt the effects ofbeing further isolated from their homecommunities and felt daunted by thecontrast between their experiences ina small rural community and theurban environment. As one noted,I’m Native—I’m a big chicken tobe in [the big city]. There was ashopping mall across the street—Iwouldn’t even go to it. I just stayedin my hotel room.Experiences in ReferralCommunitiesDue to the sustained high outflowof women from the study communi-ties, an informal protocol had beenestablished around accommodationalternatives and referral to appropri-ate care which included access to care[My husband and I] got a kitch-enette so that we could cook forourselves, but I just found it hardbecause you don’t have everythingyou need there. Like if you weretrying to make something you needsome certain spice for you’ve got togo out and spend five bucks for abottle of spice that you’re going touse one night. So a lot of times Isaid “to heck with it!” and endedproviders sensitized to the conditionsand challenges faced by women com-ing from the remote, isolated com-munities and the availability of ac-commodation that supported ex-tended families.However, despite addressing theselogistical concerns, the women inthis study struggled with their dis-placement from their communitiesand families. As one participantnoted,That was rough cause it was myfirst kid and staying in a hotel, Ididn’t like that. Cause you had tostay in a hotel the whole time youwere there and you go there for awhole month, one month beforeyou have your baby so you’re therelike when you’re eight months[pregnant].Although some participants com-mented favourably on the availabil-ity of accommodations that were con-ducive to a family-centered experi-ence (including rooms for other fam-ily member and facilities for cook-ing) many still experienced the chal-lenge of a disrupted routine and be-ing away from resources that theywere familiar with. In some instances,this lead to health consequences. Asone participant expressed,up ordering out…. And a lot ofwomen I’ve heard say, like, I gained15 pounds my last month when Iwas in town cause you just get intothat habit of eating whatever….The level of satisfaction of experi-ence in the referral community wasdirectly related to whether or notparticipants already had children, asthe reality of either bringing childrento the referral community or leavingthem behind precipitated stress andanxiety. Most participants withschool-aged children made arrange-ments for them to stay in their homecommunity with family or friends.Aside from the logistical challengesof securing care for the children, leav-ing part of the family behind lead toa sense of bifurcation for many of theparticipants. As one noted,[I couldn’t take the older ones]cause they go to school but [thebaby] was born in February so Ihad to leave them after the holi-days. It was pretty hard. I thinkit’s best if they go with you causeit’s hard, cause [then] your mindis on one thing. You’re worriedabout the baby you’re having andthe kids [you left at home].This often led to the desire to“It was pretty hard. I think it’s best if they gowith you cause it’s hard, cause then your mind ison one thing. You’re worried about the babyyou’re having and the kids you left at home.”78 CANADIAN WOMAN STUDIES/LES CAHIERS DE LA FEMMEreturn home as quickly as possible,sometimes even before the birth dueto the stress and anxiety of beingaway. As one woman commented,“At the end of it I just got to the pointwhere I said, if I don’t have this babythis week I’m going to leave anyways.”This participant recognized the con-sequences—having an unassistedbirth in her home community—andwent on to juxtapose the risks ofstaying in the referral communityand returning home.[My doctor] got in touch with aspecialist … and I just told him itcan’t be healthy for my baby eitherfor me to be depressed because that’show I feel. I feel depressed. I don’twant to be here and …[the doctor]said,  “well if she’s that far alongand she is depressed and she wantsto go home … then let her go.”Financial CostsAside from logistical challenges anda sense of separation from usualmechanisms of support that leavingthe community precipitated, almostall participants noted the financialconsequences of giving birth in areferral community. Although Abo-riginal women are compensated fortravel, accommodation and food,many noted incidental costs that theywere responsible for. As one partici-pant noted,Yeah, [I talked to my daughter]every night. It cost a lot of money.A lot of phone cards. She had ahard time with her homework.And I used to help her with herhomework over the phone.Other non-Aboriginal participantsobserved inequities in access to serv-ices for rural women. As one com-mented:I think they should pay for us to goaway. It’s not fair. You know it’sa lot of money then just addedstress that you don’t need.... Forsomebody who doesn’t have ex-tended health [care benefits], evenif you do have extended health it’sexpensive to have to put it out ofpocket first and get it back later.Social CostsBeyond financial costs incurred,the social costs of leaving the com-munity were the high levels of stressand anxiety experienced by most ofthe participants. One participant re-lated her concerns over the stress shewas experiencing in the referral com-munity to the health of her thirdbaby, drawing on her previous twopregnancies:I was concerned with my baby …from me being so stressed out.…With my first son I wasn’t stressedout through my pregnancy and hewas fine. My second son, I had avery stressful pregnancy and by thetime he was about, well, from thetime he was born, we couldn’trestrain him. He would sit in hiscar seat and he would cry and thenby the time he was about 18 monthshe was a real handful. He had alot […] you could tell there was abig difference in him. So at theend, towards the end [of my preg-nancy] when I was really stressedout, I was worried that [my anxi-ety might have the same effect as itdid on the second one.She went on to describe some mani-festations of stress she experiencedduring the time away from her com-munity, such as loss of appetite.Actually I did lose [weight] but Ithink that was the stress… I waseating, but I wasn’t eating lots. Ijust kind of ate to keep myselfgoing. I was just stressed out. I hada lot of anxiety about being thereso I lost [weight] in my last month.Another participant spoke of theadjustment period with her familywhen she did return home after giv-ing birth away:When I got home it was hardbecause the kids … were so excitedto see the baby and see their par-ents, you know, by the time youhad to bring … [the baby] into thehouse, really you haven’t been therefor so long and you’ve only beencaring for yourself for a monthand then you come home andyou’ve got three kids.… You knowit’s hard you go from almost noth-ing to overload just overnight.DiscussionDespite the social consequences ofbeing separated from their home com-munities and support structures,many participants in this study hadpositive impressions of the care theyreceived and their arrangements inthe referral communities. Participantsin this study expressed the belief thattheir physiological needs were metthrough a stable protocol involvingevacuation to referral communitiesone month before their expected duedate. They described the efforts madeby health care providers within theirlocal communities to secure appro-priate care in referral communitiesand accommodation that met theirneeds and that of their families. Yet,experiences of stress and anxietyaround leaving their communitieswere common to most women in thisstudy due to the social disruptionand sense of separation/isolationevacuation precipitated. These expe-riences were especially acute whenthe women were separated from otherchildren who remained behind intheir home community.Effects of stress on health in preg-nancy have been most closely relatedto pre-term delivery (Moutquin;Misra et al.; Mackey and Boyle;Mackey. Williams and Tiller; Cooperet al.; Hedegaard et al. 1996, 1993).This literature is part of a growingbody of work investigating the psy-cho-social determinants of stress andthe physiological implications of stresson health (Mate; Elstad). Thematicto this larger work is an understand-ing of the importance of social rela-tionships in mitigating stress(Kornelsen and Grzybowski 2004b).VOLUME 24, NUMBER 1 79This was intuitively both under-stood—and experienced—by womenin this study who expressed anxietyover loss of such support when theywere separated from their social net-works. Many tried to reassemble asense of community within the refer-ral setting either by having familyaccompany them to the birth (oftena difficult undertaking due to thetime away from the community thisentailed and the associated costs) orchoosing the location for birth basedon the presence of family. Althoughleaving the home community at thetime of birth was seen causally lead-ing to stress and anxiety for manyparticipants, underlying the actionwas a sense of loss of control: partici-pants did not have the choice to staynor  any input regarding the timingof their departure.Although we currently lack ad-equate evidence to determine policyaround the size and isolation of acommunity that would justify ma-ternity care (Kornelsen andGrzybowski 2004a), there are practi-cal limits to the size and location ofcommunities that suggest when localcare may not be feasible. This may bethe case for the isolated and remotecommunities participating in thisstudy. Nevertheless there are signifi-cant social consequences experiencedby women in this study when sepa-rated from their home communitiesto give birth. these consequences maybe mitigated by attending to provid-ing and maintaining antenatal sup-port within the communities thatwould prepare women for evacua-tion in a collaborative way and in-volve women in the decision-makingprocesses around their care. As CarolHogue et al. note:A sense of control or mastery hasbeen shown to reduce psycho-logical distress and positivelyaffect physical health, as well asto buffer the negative conse-quence of stressors on mentaland physical health. (32)Mitigation of stress may also in-volve securing family-centered ac-commodation for all women leavingisolated communities so they canbenefit from the community and so-cial support that is integral to theirlives during one of the most joyous—and potentially vulnerable—experi-ences they will have.Overall, participants from the iso-lated communities in this study didnot express a desire to birth locally,due in part to perceptions that itwould be unsafe because of the lackof local caregiver support, techno-logical resources, and transport chal-lenges (should emergency transportbe necessary). This was a significantdifference from women in commu-nities that had recently lost, or werefacing imminent challenges to, localbirthing services (Kornelsen andGrzybowski 2004b). Differences insafety issues around access to tech-nology and transport provide only apartial explanation of this difference.A more compelling influence may bethe loss of a cultural vision of localbirth. The lack of a community-basedbirthing narrative woven from thecontemporarty experiences of localwomen has a profound influence onwhat alternatives are believed to bewithin the realm of possibility. Whenthe cultural narrative around birth isexclusively one of experiences out-side their home communities, theability to imagine anything differentdisappears.Methodological limitations of thisstudy include small sample size, onegeographic area, and limited recruit-ment due to geographical challengesof distance between the research teamand the research communities. As inall qualitative research, selected par-ticipants are able to articulate morecompellingly than others. Care wastaken to adequately represent narra-tives contributing to each themeamong all participants.ConclusionIn spite of 30 years of lack of localbirthing services and an establishedevacuation protocol, women livingin remote rural British Columbiadescribed significant stressors andcosts associated with birthing in re-ferral centers. Participants in thisstudy identified barriers to achiev-ing adequate social support awayfrom home that would help to miti-gate the stress they experienced. Thepsychosocial needs of the pregnantwomen from these communitiesmust be attended to in order to en-sure positive outcomes for birthingmothers, their newborns, families,and communities.Jude Kornelsen, Ph.D., is an AssistantClinical Professor in the Department ofFamily Practice, University of BritishColumbia. She is the co-director of theRural Maternity Care Research Pro-gram. Dr. Kornelsen is the correspond-ing author for this submission.Stefan Grzybowski, M.D., CCFP,MClSc, FCFP, is Research Director,Department of Family Practice, Uni-versity of British Columbia. He is theco-director of the Rural Maternity CareResearch Program.ReferencesChamberlain, M. and K. Barclay.“Psychosocial Costs of TransferringIndigenous Women from theirCommunity for Birth.” Midwifery16 (2000): 116-122.Charmaz K. “Grounded Theory:Objectivist and ConstructivistMethods.” Handbook of QualitativeResearch, 2nd ed. Eds. N. K. Denzinand Y. S. Lincoln. Thousand Oaks,CA: Sage, 2000. 514-519.Cooper R. L., R. L. Goldenberg, A.Das, et al. “The Preterm PredictionStudy: Maternal Stress is AssociatedWith Spontaneous Preterm Birthat Less Than Thirty-Five WeeksGestation.” American Journal ofObstetrics and Gynecology 175(1996): 1286-92.Elstad J. 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