Rural maternity practice: how can we encourage family physicians to stay involved?

During the past decade, many rural jurisdictions in Canada have witnessed precipitous closures of maternity services. Although reasons for closures are often location-specific, they tend to be related to human resource challenges involving nurses, general practitioner surgeons, family physicians and specialists; lack of access to specialized services (e.g., limited access to epidural anesthesia, labour augmentation or cesarean delivery back-up); and a trend toward centralization across the spectrum of delivery of health care services in Canada. It is becoming clear that, among these contributing factors, the most significant challenge is the recruitment and retention of providers in rural locations and the need for appropriate incentives to improve physician participation. Across Canada, the proportion of births attended by family physicians is diminishing and varies considerably from a low of 23.6% in Prince Edward Island to more than 77.2% in British Columbia. Many provinces have already lost most of their family physician involvement in maternity care and British Columbia is poised to experience the same decline in family doctors who practise obstetrics. These challenges to the provision of care are characteristic of a rural context and have given rise to innovative solutions for sustaining services. One such solution is on-call remuneration agreements, as have occurred across rural Canada during the past 10 years. For example, in British Columbia an on-call remuneration agreement was reached in 2001 between the BC Medical Association and the British Columbia Ministry of Health, which included financial support for coverage of emergency and specialist services, but not maternity care provided by family physicians. Other provinces have implemented on-call coverage plans for emergency care in rural environments, such as the Rural On-Call Remuneration Program in Alberta, the Emergency On-Call Coverage Program in Saskatchewan and the Hospital On Call Coverage Program in Ontario, and have included support for on-call maternity services in an attempt to staunch the loss of family physician involvement in obstetrics. A review of the Alberta Rural OnCall Remuneration Program has demonstrated high satisfaction among rural physicians with the program. In Ontario, the pilot program for the Hospital On Call Coverage Program started in 2000 and has been re-funded and expanded in response to positive pilot outcomes.