Accessing maternity care in rural Canada: there's more to the story than distance to a doctor

Drawing upon a comparative, qualitative study of the experiences of rural women accessing maternity care in two Canadian provinces, we demonstrate that availability of services, having economic and informational resources to access the services offered, and the appropriateness of those services in terms of gender, continuity of care, confidentiality, quality of care, and cultural fit are key to an accurate understanding of health care access. We explore the implications of living rurally on each of these dimensions, thereby revealing both gaps in and solutions to rural maternity care access that narrower, proximity-based definitions miss.     

Stress and anxiety associated with lack of access to maternity services for rural parturient women

Objective: The objective of this study is to compare the level of stress and anxiety between women resident in communities with different degrees of access to local maternity services. Design: Cross‐sectional survey. Setting: Fifty‐two communities across rural British Columbia with different levels of access to maternity care services (ranging from no services to local specialist obstetrician). Participants: A total of 187 women, 40 of whom were from communities with no local access to services. Main outcome measures: Stress score on the R ural Pregnancy Experience Scale including financial and continuity of care subscales. Results: Parturient women who had to travel more than one hour to access services were 7.4 times more likely to experience moderate or severe stress when compared to women who had local access to maternity services. Conclusions: Lack of access is strongly associated with stress in rural parturient women.     

Maternity care as an essential public service: a proposed role for state government.

This paper describes some of the current problems in assuring basic maternity care as an essential community service in the rural state of Vermont. Solving the cost of care problem will still leave large gaps in the ability of our maternity care system to provide continuous and high-quality maternity care for all pregnant women. The problem of access is not only a temporary aberration of the current medical care system, but a central and identifying characteristic of it. Maternity care services are as essential as other community services such as utilities and education. The authors propose that the state should assure the availability and quality of maternity care services as it would other essential services. The development of a statewide care system using a nurse midwife model of services is suggested.     

Rural maternity care and health policy: parents' experiences

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty‐three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re‐evaluated in order to improve rural Australians' access to vital health services such as maternity care.     

An overview of maternal and infant health services in rural America.

Economically disadvantaged rural families, like their urban counterparts, face significant difficulties obtaining adequate maternity and infant health care resulting, in part, from an unequal distribution of resources as well as economic and racial barriers to health care nationwide. Rural women and infants must contend with additional access problems that reflect the inherent constraints of rural existence as well as specific state policies that exacerbate the barriers associated with isolation. This article provides an overview of the availability and accessibility of maternal and infant health services in nonmetropolitan America and identifies policy reforms to improve access to care.     

Change in Oregon Maternity Care Workforce after Malpractice Premium Subsidy Implementation

Objectives. (1) To determine the proportion of maternity care providers who continue to deliver babies in Oregon; (2) to determine the important factors relating to the decision to discontinue maternity care services; and (3) to examine how the rural liability subsidy is affecting rural maternity care providers' ability to provide maternity care services.
Study Design. We surveyed all obstetrical care providers in Oregon in 2002 and 2006. Survey data, supplemented with state administrative data, were analyzed for changes in provision of maternity care, reasons for stopping maternity care, and effect of the malpractice premium subsidy on practice.
Principal Findings. Only 36.6% of responding clinicians qualified to deliver babies were actually providing maternity care in Oregon in 2006, significantly lower than the proportion (47.8%) found in 2002. Cost of malpractice premiums remains the most frequently cited reason for stopping maternity care, followed by lifestyle issues. Receipt of the malpractice subsidy was not associated with continuing any maternity services.
Conclusions. Oregon continues to lose maternity care providers. A state program subsidizing the liability premiums of rural maternity care providers does not appear effective at keeping rural providers delivering babies. Other policies to encourage continuation of maternity care need to be considered.     

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.     

Improving poor women's access to maternity care: Findings from a primary care intervention in Burkina Faso

To date, there has been little progress in reducing wealth inequities in access to maternity care. This paper describes the results of a maternal health intervention in Burkina Faso that was aimed at increasing access to skilled maternity care by improving availability and quality of maternity care, particularly at primary care health facilities, and promoting its use before, during, and after delivery. Post-intervention data show a large overall increase in use of facility-based maternity care in the intervention district, particularly at primary care facilities, but little change in the comparison district. In addition, large wealth inequities in the use of professional care during childbirth were almost eliminated in the intervention district while they increased in the comparison district—both among all women, and among the subset of women who reported experiencing complications during delivery. Study results suggest that efforts to upgrade maternity services at primary care facilities may be key for improving poor women's access to and use of skilled care during childbirth.     

山东和宁夏6县新农合对妇幼卫生服务的报销制度安排研究

目的:分析研究地区新农合对妇幼卫生服务的报销制度安排。方法:分层随机抽取山东和宁夏6个县,分析当地的新农合方案,并深入访谈相关工作人员。结果:山东和宁夏6个县的新农合服务包都包括了一些妇幼卫生服务,根据纳入服务的不同,分为3种方式,分别为保健方式、医疗方式和综合方式,纳入的服务呈现出重医疗轻保健的状况;新农合妇幼卫生服务的补偿政策呈现出纳入项目增加,报销比例上升,逐步涉及保健项目的变化趋势。结论:预防保健的群体效益和社会效益要远高于个体医疗,随着筹资水平的提高,可以逐步纳入部分保健服务。     

Developing Policies Responsive to Barriers to Health Care Among Rural Residents: WhatDo We Need to Know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies hove grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.     

How far?: Using geographical information systems (GIS) to examine maternity care access for expectant mothers in a rural state

Various factors have made rural access to maternity care a significant problem for rural women. The geographic distance between a mother's county of residence and the county in which she gave birth was examined in a rural state. Analyzing North Dakota county-level data using geographic information system (GIS) software, women from over half of the state's counties, making up nearly 18% of all births, were found to be over 40 miles to the hospital in which they gave birth. These findings suggest that rural women may experience significant geographic barriers as they receive health services in the prenatal, delivery, and postpartum periods of their pregnancy. We highlight the value of GIS, particularly geovisualization power, and note models of care that may be effective for rural women.     

Access to Specialty Health Care for Rural American Indians in Two States

ABSTRACT:  Context: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. Purpose: To examine specialty service access among rural Indian populations in two states. Methods: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). Findings: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. Conclusions: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.     

Brutal neglect: Australian rural women's access to health services

Access to health services in rural Australia has been particularly problematic because of the vast geographical areas and the sparse population distribution across the inland. The focus on health servicing has been very much on primary health care with most attention being giving to the distribution of doctors in rural Australia. This study takes a closer look at rural health servicing through the eyes of women in rural Australia. Drawing on a survey of 820 women, the study revealed that a focus on primary health care may be resulting in a lack of attention to women's health in areas, such as maternity models of care, domestic violence and mental health. The study also reveals the disquiet of Australian rural women at the poor state of health services.     

Adequate Access to Posthospital Home Health Services: Differences Between Urban and Rural Areas

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.     

How Far?: Using Geographical Information Systems (GIS) to Examine Maternity Care Access for Expectant Mothers in a Rural State

Various factors have made rural access to maternity care a significant problem for rural women. The geographic distance between a mother's county of residence and the county in which she gave birth was examined in a rural state. Analyzing North Dakota county-level data using geographic information system (GIS) software, women from over half of the state's counties, making up nearly 18% of all births, were found to be over 40 miles to the hospital in which they gave birth. These findings suggest that rural women may experience significant geographic barriers as they receive health services in the prenatal, delivery, and postpartum periods of their pregnancy. We highlight the value of GIS, particularly geovisualization power, and note models of care that may be effective for rural women.     

Addressing health system barriers to access to and use of skilled delivery services: perspectives from Ghana

Poor access to and use of skilled delivery services have been identified as a major contributory factor to poor maternal and newborn health in sub‐Saharan African countries, including Ghana. However, many previous studies that examine norms of childbirth and care‐seeking behaviours have focused on identifying the norms of non‐use of services, rather than factors, that can promote service use. Based on primary qualitative research with a total of 185 expectant and lactating mothers, and 20 healthcare providers in six communities in Ghana, this paper reports on strategies that can be used to overcome health system barriers to the use of skilled delivery services. The strategies identified include expansion and redistribution of existing maternal health resources and infrastructure, training of more skilled maternity caregivers, instituting special programmes to target women most in need, improving the quality of maternity care services provided, improving doctor–patient relationships in maternity wards, promotion of choice, protecting privacy and patient dignity in maternity wards and building partnerships with traditional birth attendants and other non‐state actors. The findings suggest the need for structural changes to maternity clinics and routine nursing practices, including an emphasis on those doctor–patient relational practices that positively influence women's healthcare‐seeking behaviours. Copyright © 2015 John Wiley & Sons, Ltd.     

Hospitalization among migrants in Italy: Access to health care as an opportunity for integration and inclusion

This paper analyzes migrant access to health care by comparing hospitalizations of native and immigrant population with respect the Tuscany Region (Italy). In the analyses, a critical gap both for legal and undocumented migrant population is highlighted. Indeed, we found some key differences between the migrant and native populations related to the use of specific hospital services in Tuscany and, indirectly, of community and primary care services. Moreover, especially for undocumented migrants, hospitals seem to be the only point of access to the health‐care system for migrant populations. The results suggest that the Italian health‐care system is unable to ensure an equitable access to health services. In this context, maternity care could be a key point of access to the welfare system that allows participation in the health system not only for mothers but also for all migrant family members.     

Proportion of family physicians providing maternity care continues to decline

Family physicians traditionally have played an integral role in delivering babies as a component of the comprehensive care they provide for women. The proportion of family physicians who report providing any maternity care continues to decrease. This trend is particularly concerning because family physicians are the most widely distributed specialty and are essential to health care access in rural areas.     

Access to Care for Rural Medicare Beneficiaries

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.     

Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends

Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010. Using a cross-sectional study design, logistic regression analysis was performed to examine association between maternity care provision and various physician demographic and practice characteristics. Maternity care provision by family physicians declined from 23.3 % in 2000 to 9.7 % in 2010 (p < 0.0001). Family physicians who were female, younger and US medical graduates were more likely to practice maternity care. Practicing in a rural setting (OR = 2.2; 95 % CL 2.1–2.4), an educational setting (OR = 6.4; 95 % CL 5.7–7.1) and in either the Midwest (OR = 2.6; 95 % CL 2.3–2.9) or West (OR = 2.3; 95 % CL 2.1–2.6) were the strongest predictors of higher likelihood of providing maternity care. While family physicians continue to play an important role in providing maternity care in many parts of the United States, the steep decline in the percentage of family physicians providing maternity care is concerning. Formal collaborations with midwives and obstetrician-gynecologists, malpractice reform, payment changes and graduate medical education innovations are potential avenues to explore to ensure access to maternity care.