Case Study on the Implications of Closures of Rural Maternity Services
August 2005 – December 2007
- Principal Investigator: Jude Kornelsen
- Co-Investigators: Andrew Kotaska and Liz Cooper
- Support Team: Shelagh Levangie, Georgia Walton, Evelyn Eng
- Community Advisory Research Team: Louisa Willie, Dawn Wilson, Jennifer Carpenter, Pauline Waterfall, Marie Duperrault, Steve Cairns, with the assistance of Wanda Christianson who provided guidance and support in the research process.
In 2000, residents of Bella Bella lost access to local maternity services. Since that time parturient women have been referred out of the community for prenatal diagnostics and for ultrasound. Provincial data suggests that when a community loses its local maternity services, newborn outcomes are worse than when services are maintained, regardless of where women give birth. This research investigates what the loss of local services means for the health of mothers and their babies, what the costs are to band councils, and how women feel about the quality of their birthing experiences.
From October 2005 – July 2006 a research team from the Centre for Rural Health Research, Department of Family Practice UBC, undertook a study of the implications of the closure of local maternity care under the guidance of the Heiltsuk Maternity Care Study Community Research Advisory Committee. The objective of the study was to document the implications of the closure of local services by:
- Undertaking chart reviews to document the maternal-newborn outcomes of women who had left the community to give birth with women who gave birth locally;
- Undertaking an analysis of band travel records to determine costs incurred to the band for medical travel related to maternity care;
- Undertaking a survey to document women’s experiences of birth, locally or away; and
- Undertaking in-depth interviews to document women’s stories of their experiences of birth.
Findings from the chart reviews reveal that there were no statistically significant differences in outcomes before and after closures on all variables measured. However, due to the small sample size, there was insufficient power to detect clinically meaningful differences, and hence, it is necessary to interpret this data from within a larger context of maternal – newborn outcomes based on service delivery levels.
Findings from the analysis of band council records revealed women and families spent an average of 29 days out of the community in referral centres costing an average of $108.07/day and $3732 per individual for the duration of their stay outside of the community.
Findings from the survey revealed that of the 55 women who completed the survey, 35 gave birth away from the community (the majority at BC Women’s) and 20 gave birth in Bella Bella/Waglisla. Themes include influence of care providers in decision-making (higher for those who left the community than for those who stayed), the importance of the presence of family during labour and delivery and the overriding belief that women should be able to give birth in Bella Bella. Of the participants who chose to leave, almost all did so due to the desire for access to pain medication and the belief in the importance of immediate access to technology in case it was necessary. Time of year of delivery was not a significant concern for either women who stayed in the community or women who birthed elsewhere. The majority of respondents felt local birth was important to the culture and community of Bella Bella.
Results of the in-depth interviews illuminated attributes of birthing locally including the value of emotional and practical support from the community and the importance of local birth both individually to women as members of the Heiltsuk nation and to the wider community. Descriptions of birth away focused on some of the factors that influenced the decision-making process of those who chose to leave and the social, financial and logistical implications for those who had no option. Nine of the women we listened to gave birth in Bella Bella/Waglisla and 3 gave birth in a referral community. All of the women who remained in the community gave birth before 2000, when local services, including cesarean section back-up, were available.
Currently there is ambiguity regarding the future of maternity services in Bella Bella/Waglisla. Current data suggests that the community could support local intra-partum care without surgical capability. Given this, the level of service desired in Bella Bella/Waglisla must be determined honoring an inclusive, community-based process with involvement from key stakeholders. In order to productively move forward, this process should also include a review of the recent history of local birthing services with attention given to describing the decision making process that resulted in the closure of services in 2000.
If the community decides to continue the current program of evacuation from the community for birth, it must be done with a recognition that a comprehensive program of birthing support services must be in place for the prenatal and post-partum period and be integrated with care provided in the referral site. Likewise, supports must be in place in the referral community to ensure the best possible experience for women from the community.
If the community decides to reestablish local birthing services, a community-wide informed consent process must be undertaken that acknowledges the spiritual, social and psychological as well as physiological risks and benefits of local services and services away. A screening protocol as well as an evaluation of the physical infrastructure and competency of medical, nursing and support staff should also be undertaken.
Kornelsen, J., Kotaska, A., Waterfall, P., Willie, L., Wilson, D. (2010). The geography of belonging: The experience of birthing at home for First Nations women. Health & Place, 16 (4), 638-645.
Kornelsen, J., Kotaska, A., Waterfall, P., Willie, L., Wilson, D. (2011). Alienation and resilience: The dynamics of birth outside their community for rural First Nations women. Journal of Aboriginal Health, 7 (1), 55-64.