Closing rural maternity services: Is it worth the risk?

W from rural and remote communi t ies with no local access to maternity services have worse maternal and newborn outcomes than women from similar communities with local access to even limited birthing services.1 Canadian studies have demonstrated that distance to services affects maternal and newborn outcomes.2–4 Perinatal mortality is higher for populations of women who are more than 4 hours away from maternity services.1 Women who live 2–4 hours away from the nearest maternity service show in creased rates of interventions, and women living 1–2 hours away from services have increased rates of unplanned out-of-hospital deliveries.1 There are trends across all these groups toward increased prematurity.5 Parturient women from commun ities with no local intrapartum services are 7.4 times more likely to report moderate to severe stress than women from rural communities with local birthing services.6 Loss of local maternity services in a rural or remote community is more than just a social and financial challenge. Translating these research findings into policy is essential: how do these issues affect clinical care, health services planning and risk management? Clinical decision-making optimally follows full discussion of the diagnostic and therapeutic choices available with an exploration of the various risks and benefits, including social risks, as well as a discussion of alternative choices.7 Although this approach may be possible in a well-resourced urban environment, a different set of issues arises in a rural and remote environment, where choices for birthing women are limited by access.8,9 Decision-making will be influenced by the financial costs or the social and cultural challenges resulting from an absence from home.8,10,11 This may be particularly significant for women living in areas with limited birthing services (without local surgical backup). In rural and remote settings, maternity care providers and their patients weigh possible clinical risks associated with birthing locally against the social and other challenges involved in travelling away from home to access services. Women may elect to accept some potential clinical risk to mitigate an apparent social or financial risk. This leads to difficult decisions for maternity care providers in small communities who may be without the surgical backup needed to manage an unexpectedly complicated delivery. The question of whether or not a maternity care service should be supported adds another layer of complexity to analyzing risk. If a decision is made by health authorities to cease maternity services in a rural community, clinical decision-making is simplified. Services are no longer available to women, so they must travel to access services somewhere else. This is particularly challenging, however, for rural women with uncomplicated pregnancies, previous vaginal deliveries and young children at home. Although health professionals may be relieved by no longer being asked to manage the uncertainty of birth in a low-resource environment, they also