Toward a Policy Framework for Sustainable Rural Obstetrics and Surgical Care in Canada

[Tables and figures accessible in the downloadable PDF]

Toward a Policy Framework for Sustainable Rural Obstetrics and Surgical Care in Canada

R Douglas Wilson, MD, FRCSC, Professor Emeritus, Department of Obstetrics and Gynecology, Alberta Health Services, Cumming School of Medicine, University of Calgary

Abstract

A national policy framework is needed to support high quality, sustainable rural healthcare in Canada. There is a particular need for improvement of obstetric and surgery services in the rural and remote communities of Canada. Using a scoping review, existing policies across Canada were examined and learnings were distilled to inform a discussion of the elements of an appropriate framework. Long-term vision, planning, and sustained funding were identified as missing essential strategic elements from the current policy approaches. A “plan, recruit and retain” framework proposed by an international collaboration of researchers including Canadians in a project funded by the European Union, is recommended as a starting point for a made-in-Canada strategy to support improvements in remote and rural healthcare services. Additional recommendations are gleaned from several reports published by a variety of Canadian sources. Conclusion: A directed federal-provincial process, possibly via a Royal Commission and initially supported provincial and federal rural healthcare transfer payments, is required as the three functional process areas (plan, recruit, retain) must be approved and in place for the long-term success of rural obstetrics and surgery care needs. The principal elements of any framework strategy must include equitable, supportive, and sustainable health care provider agreements with directed but necessary redundant human resource requirements; rural patient focused access and quality care; and clear political – clinical care policy.

Key Words: Canada, rural, healthcare, obstetrics, policy.

Citation: Wilson, R Douglas (2023). Toward a Policy Framework for Sustainable Rural Obstetrics and Surgical Care in Canada. Canadian Health Policy, FEB 2023. https://doi.org/10.54194/GTEX1486 www.canadianhealthpolicy.com

Introduction

Rural healthcare should be an important national issue. It is estimated that approximately 20% of Canadians live in communities or regions that can be defined as rural. [1, 4] TABLE 1 shows categorical definitions published by British Columbia health services for remote and rural communities, which use population as the main distinguishing factor. The CIHI Rural Health Service Decision Guide provides context for the complexity of rural care considering the geography, population, and health system-community factors [4]. TABLE 2 summarizes factors which reflect how rural residents may have different needs for health care services than their urban counterparts.

Rural healthcare advocates continually report underserviced needs but policy development and implementation is not a key priority for the federal or provincial governments [5-7, 13-21]. Since the early 1990s, researchers have identified challenges regarding the adequacy of fiscal and human resources supporting rural healthcare services, with access to obstetrical and surgical services being particularly problematic. [5-7]. Rural residents have access to a smaller variety and number of health services and providers when compared to urban residents. The quality and accessibility of rural healthcare has both patient-level and societal effects: inadequate access to essential medical services could negatively impact the health of rural populations and this could also have negative consequences for rural economies. [2] The development of contemporary rural public health policy requires a realistic approach that identifies the trade-offs for rural public heath implementation (TABLE 3) [12]. This paper is intended to inform discussion about an appropriate structure for a revitalized rural healthcare planning process with a particular focus on the accessibility and sustainability of obstetric and surgery services.

A scoping review methodology was used for the analysis, to synthesize and assess the scope and characteristics of the research literature regarding rural healthcare. [8, 9] Heterogeneous literature labelling was done with relevance to date, location (country or context), source (peer-reviewed or grey literature), and origin (health care discipline or government policy). A total of approximately 200 data sources were evaluated and categorized with the final total of 126 being selected for review. A significant proportion of the scoping data sources were from peer-reviewed sources, identified through PubMed (89/126) while the remaining grey references were from federal and provincial government controlled-public websites with possible inherent bias. In additions, key words, report titles, peer-reviewed references, and author names were utilized. This scoping review was focused on primarily rural directed obstetrics and surgery in Canada but other information from countries was considered with identified rural needs. PUBMED was the evidenced based resource, English only, using keywords rural health-care access, rural health-care quality, rural healthcare outcomes, rural health-care spending, rural healthcare reform, and maternity and surgery care models. The grey literature internet search used keywords, provincial healthcare priority, provincial healthcare business planning, and Canadian Institute for Health Information (CIHI). This scoping review has identified limited but adequate data sources (peer-reviewed and grey literature) for a national evidenced-based policy review of Canada’s and provincial rural obstetrics and surgery healthcare process (past and present) and opportunities for healthcare model change and sustainability. A scoping review checklist (score 17/20) is provided in the appendix.

Summary of Key Learnings

Challenges of Remote and Rural Healthcare: Maternity and Surgical Services

Rural maternity care is provided by local maternity care teams usually led by family physicians, midwives, and nurses, although in certain rural locations the additional support is provided by general surgeons, GP-anesthetists, obstetrician-gynecologists, and/or family physicians with additional surgical training. The closure of rural maternity care programs has occurred due to provincial regionalization of maternity care services, cost cutting measures, administrative pressures, and the lack of skilled maternity care providers. Maternity programs are dependent on and require, not only clinical providers, but on focused clinical support services (diagnostic imaging, laboratory testing, and blood banks, service appropriate/functional equipment, and effective maternal-neonatal transport systems (large distances/all types of weather) [6].

Some rural community hospitals provide maternity care for low-risk women but without local access to caesarean delivery. These hospitals are resourced similarly to birth centers and by combinations of midwives, family physicians, and registered nurses. There is evidence for quality maternal – newborn outcomes, which allow pregnant people to stay in their rural communities. These Level I nonsurgical hospitals should be collaboratively linked to larger regional sites for their clinical and specialist consultation support [21]. The physician and hospital competency skills will differ, based on the human resources and geographic locations, but audit has indicated that the majority of low-risk pregnant people will have a safe, normal physiological birth with minimal intervention, but pregnant people need to understand their risks of remaining in certain birthing locations [13, 22].

The place-of-birth and the ‘informed-choice decision’ is an important autonomy choice for pregnant people. The choice requires that there are maternity and surgical care providers with the necessary clinical skills located in the rural environments (consent topics – risks, benefits, alternatives, indications for and timing of transport to a surgical setting). Supporting pregnant people, who plan to have their births at home, in birth centers, or in level I hospital, without local access to caesarean delivery, respects the autonomy of the pregnant person giving birth and her family [13].

The second cohort of Level I hospitals offering local caesarean delivery services, are staffed by midwives and rural family physicians, some having advanced surgical training (FPESS), anesthesia providers and general surgeons with caesarean delivery skills. In addition, the hospital requires providers and resources for newborn care. The rural maternity care providers will commonly offer planned local births for pregnant people with low to moderate degrees of risk, when the birth is anticipated to be uncomplicated and neither mother nor newborn is likely to require resources beyond the local capacity. Such maternity care services may meet the needs of up to 80% of the local catchment population. These rural programs are vulnerable due to low surgical procedural volume, creating acute challenges for staffing and instability or fluctuation in the availability of local access to caesarean delivery [22].

The opportunity to reduce the number of pregnant people who need to travel and leave their rural community for maternity care is an important goal but requires balances for quality, safety, and patient autonomy [12]. Evacuation for childbirth from rural and remote Indigenous communities (Canada) is associated with numerous emotional, social, and cultural harm outcomes for Indigenous pregnant people. The factors related to maternity evacuation were local evacuation policies, institutional coercion, remoteness, and maternal-fetal health status. Outcomes related to the impact of evacuation are maternal -child health morbidity, financial hardships, family disruption, cultural and community wellness, subsequent engagement with healthcare services, self-determination, and evaluation of healthcare services quality [23].

Characteristics and in-hospital outcomes for pregnant people requiring pregnancy-related aeromedical retrieval compared to non-retrieved urban cohorts (Australia) identified that the pregnant people were younger (28.0 vs 30.0 years 95% CI 27.7-28.3) with higher rates of overweight/obesity (52.2% vs 45.1%95% CI 47.5-56.9) and smoking during pregnancy (14.0% vs 9.9% 95% CI 12.5-15.5). The most common indication for transfer was threatened pre-term labor and delivery. Over one-third were delivered by caesarean delivery with a median gestational age at birth of 33.0 weeks (95% CI 32.7-33.3) [23]. Long-distance travel for birthing among Canadian indigenous and non-indigenous pregnant people identified significant inequities in access to birth close to home compared to non-indigenous people, primarily in rural areas and independent of pregnancy medical complications (indigenous travel >200 kms 9.8% vs 2.0%; OR 5.45 CI3.52-8.48) [24]. Rural Swedish pregnant people, living far from the hospital delivery ward, were studied in longitudinal cohort (mid pregnancy and postpartum) related to their fear of birth. Fear was highest during pregnancy, lower after birth, and a further increase was associated with the consideration of future birth. Factors associated with developing fear after birth were mainly related to experiencing an emergency caesarean delivery, epidural, augmentation, or increased need for neonatal care. Reduction of fear was associated with antenatal support [26].

Rural general surgery services are generally available in communities with populations > 20,000. British Columbia surgeons, in small or mid-sized communities, perform significantly more non-core surgical procedures than surgeons in larger communities. As general surgery residency training has become more focused, the present surgical graduates are less likely to be prepared for these additional surgical procedures compared to the trained surgeons prior to 1990 [14, 15, 27] (TABLES 4A and 4B).

Surgical task-sharing in the Western Canadian Artic used a networked model of care (Edmonton, Yellowknife, Inuvik) to provide local caesarean delivery, gastro-intestinal endoscopy, and emergency on-call support with integration of a family physician with enhanced surgical skills and specialist surgeons. The study was undertaken using semi-structured interviews with 22 stakeholders and concluded this network approach was able to address healthcare surgical gaps [28].

A 10-year review of surgical safety discussed the contributing factors to surgical misadventure from physician factors (64% in pre-operative: informed consent; intra-operative: errors in clinical decision making; post-operative: team instructions, documentation of treatment plan, informed discharge) and from system factors (45% in lack of standardized protocols and evaluation of outcomes; lack of education; lack of culture of safety) [29, 30]. This information highlights the surgical safety requirements for primary training and subsequent maintenance of skills.

The rural-urban differences in health care access among women of reproductive age identifies fewer skilled providers for maternity care and fewer visits for care, resulting in higher morbidity and mortality rates for both women and newborns [31-34]. Rural populations, with ethnic/racial/immigrant components, may have additional quality and access issues [35-41].

The concept of ‘applying a subpopulation lens by population health’ could be used to guide policymakers regarding remote and rural health. The evaluation of the subpopulation characteristics (special attributes; relevant social determinants of health) and approaches (clinical adaptations; institutional or organizational partners; policies) should be required by the responsible government groups [42].

Current State of Policy Development and Implementation

Policy directives for rural healthcare appear each decade but examples of successful and sustained rural health care implementation are limited. A brief review of the policy development history regarding remote and rural healthcare is presented below in separate sections pertaining to recommendations of health professions and policy related to federal, provincial and regional governments.

Health Professions

The 1998, the Joint Working Group ‘Position Paper’ on Rural Maternity Care identified multiple recommendations, with an overview of current information directed on issues in maternity care relevant to rural populations, within a framework and three directed themes level of service/collaborative care teams/educational process for CME, Safety, and Quality [6].

The 2016 Western Collaborative Network White Paper used the process of key themes or policy opportunities for consideration of clinical services and education with continuing supportive fiscal arrangements [17]:

• The planning of rural networks should be based on geographic catchment and population needs
• The local delivery of rural health services should be part of a cohesive system of regional programs to deliver surgical and maternity services within an integrated, horizontal, and non-hierarchical system of regional programs, not as stand-alone institutional services
• The purposeful upstream and downstream collaborative alignment of providers and services should be built on trusted relationships and an interdisciplinary community of practice
• The promotion of transdisciplinary lifelong learning and quality improvement culture is required
• The development of a competency-based curriculum to train and support rural providers is required

The 2021, the Consensus Statement on Networks for High-Quality Rural Anesthesia, Surgery, and Obstetric Care in Canada [20] have reviewed the international literature and outcomes and includes personal observations from rural services in Canada. The consensus suggests that the most effective way to provide a robust rural obstetric/surgical infrastructure is through a networked system of specialist–generalist surgical care (“hub and spoke” model). Within Canada, networks of care could include a community of specialists and family physicians with enhanced training allowing a bridge over the urban–rural clinical care divide. The consensus describes the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, with delivery as close to home as possible:

• Networks require financial resources and high-functioning relationships.
• Onsite anesthesia, surgery, and operative delivery programs sustain rural maternity care close to home.
• The development of networks of specialist and non-specialist providers is the policy option recommended to sustain these local anesthesia, surgery, and operative delivery programs.
• Surgical and maternity triage needs to be embedded within networks to address the tension between sustainable models of delivery and local access to care.
• Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks.
• Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny.
• Maintenance of quality and provision of continuing professional development in low-volume settings represent a mutual value proposition. Because they are both foundational and challenging, they deserve to be addressed collaboratively by our organizations.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) opinion, ‘Attendance at and Resources for Delivery of Optimal Maternity Care, has recommended that all community birthing settings (home, birth centers, and level I hospitals), meet the following quality and safety requirements [22]. A team-based protocol and process will allow for consistency and quality outcomes which in turn will create an environment for clinical provider retention:

• Informed choice discussions should be conducted with pregnant people in the prenatal period, including reasons for transport, risks of transport, and possible delays and emergency measures applicable in community setting.
• Situational awareness (timely attendance; continuing updating of informed consent may be required)
• Consultation with an obstetrician should be available by telephone or technology-enabled conferencing/documentation (progress and details of the labor process in appropriate location-based format paper or EMR)
• Timely communication among all healthcare team members within the birthing location, between hospital areas, and other institutions for transfer or emergency guidance (clinical and social risk factor review; clear hand-over and information transfer)
• Transport mechanisms should be available, and transport processes should be rehearsed jointly with the maternity care and transport teams.
• Fetal surveillance, interpretation, and response
• Medications to manage obstetrical emergencies, such as magnesium sulfate, antenatal corticosteroids, and tocolytics, ideally should be available to initiate management prior to a potential transfer.
• Medications to treat postpartum hemorrhage ideally should be available in all community birth settings.

Federal Government and Agencies

The federal government, through Health Canada Departmental Plan 2020-2021, has published their Core Responsibilities for Health Care Systems and Health Protection/ Promotion but with no clear directive for the rural healthcare population. The document simply stated that “Health Canada will engage with provinces, territories, and stakeholders to explore innovative approaches including new service delivery models, digital, and virtual care solutions, to help ensure that every Canadian has access to a primary care provider or team.” [43]

Provincial-Regional Governments

Provincial policy decisions are often proposed using non-collaborative urban healthcare models, without an understanding of the potential negative effects on rural communities. Rural communities need to have rural-based solutions and need to participate in the development of regional capacity using innovation, experimentation, and discovery for their solutions [18, 46]. Three Canadian provinces (British Columbia; Alberta; Ontario) have made important collaborative contributions to creating and supporting successful rural obstetrical (and surgical) services.

British Columbia was able to establish more sustainable rural services, through the Joint Standing Committee (JSC) on Rural Issues, created under a provincial 2001 Rural Subsidiary Agreement [47].

The Rural Health Services in BC: A Provincial Policy Framework to Provide a System of Quality Care (Cross Sector Policy) is a detailed planning and action framework with a goal to address the healthcare service priorities through a rural lens. Priorities were identified to align with Triple Aim goals for: improving the health of populations; improving the patient experience (quality/satisfaction); and reducing the per capita cost of health by focusing on quality (effectiveness/appropriateness) and the efficiency of healthcare delivery [48-50].

A British Columbia, Canada evidenced-based program highlights the success of a rural surgical and obstetrical network focusing on five key pillars of clinical coaching, continuing quality improvement, remote presence technology to mitigate geographic challenges, sustainable local surgical capacity, and evaluation of dimensions of network function and clinical outcomes [50]. Additional clinical publications support the network methodology [52-55].

The Alberta maternity care process has used the Alberta Health Services (AHS) Strategic Clinical Network for Maternal Newborn, Child and Youth (MNCY) Network and the AHS Provincial Community and Rural Maternity Plan Steering Committee, for a rural planning process to support access, quality, and sustainability of fiscal and human resources, using collaborative linkages between EMS, maternity care, surgery, and connections to Level 2 hospital facilities [56]. MNCY reproductive quality care processes have developed Alberta Antenatal Pathways for both rural and urban obstetrical care [57].

The Ontario process has considered a framework of rural health hubs for the integration of health planning, funding and delivery in Ontario rural, remote and northern communities [58-60]. There is recent concern that Northern Ontario is becoming a maternity care ‘desert’ with non-obstetrical service hospitals (35 rural and 5 urban) rising from 37.5% (1999) to 60% (2020). The patient travel time for access to maternity care has increased and access to antepartum care has decreased (urban 65%; rural 49%), although there has been no decrease in MD numbers [61].

Rural maternity models of care require interprofessional collaboration (shared on-call responsibilities/funding, consultation and referral) but these collaborations are not without challenges due to different cultures of training, variable sources for evidenced-based maternity care information, and different work-load expectations [62].

The turnover factors for Ontario rural small-town MDs identified reasons such as the lack of partner career prospects, provider burnout, and lack of rural opportunities and amenities. Other MD factors identified were the lack of designated contract flexibility and rural experienced medical graduates [63-66].

Another Ontario human resource evaluation indicated providers with high intensions to stay, workplace and community satisfaction, and full recruitment into two physician service complements [67].

A rural health strategy in Saskatchewan identified the need for better management of chronic disease, for cost-effective programs and services, and for recognition of the gaps in service delivery (inequitable distribution; limited scope of practice; travel support for rural to urban) [68].

There is a need for clinical education, practice support, and policy reform for rural and remote health care services [69-72]. The ‘Review of Family Medicine Within Rural and Remote Canada’ discussed the policy gaps, considerations and strategies for clinical evaluation, rural medical education programs, support for rural clinical teachers, policy for support and funding, and pan-Canadian approach for family physician rural education [69].

A systematic review considered the use of educational interventions, to ensure the availability of rural physicians. Five main types of intervention, often used in combination, were preferential medical school admission from rural area applicants, curriculum relevant to rural medicine, decentralized education, practice-oriented learning in rural areas, and compulsory service periods in rural areas after graduation. The interpretation indicated that changing the focus of undergraduate medical education towards the development of knowledge, skills, and teaching areas that will provide doctors-in -training with competencies they need to work in rural areas. This initiative will potentially enhance rural physician recruitment [73].

Additional planning opportunities for rural obstetrics and surgery are summarized in the planning topics of education, obstetrics, diagnostic care, anesthesia, surgery and clinical diversion transfer (Table 5) [27, 74-90].

The planning process requires that audit, data collection, and research measurement is an important factor to measure quality, safety, and effectiveness with focused requirements especially for indigenous healthcare evaluation [91, 92].

Improving Remote and Rural Healthcare: Plan, Recruit, and Retain

Recruitment and retention of physicians and other health professionals is an urgent rural healthcare service need. There is a shortage and maldistribution of the physician and nursing workforce [94, 95, 96]. The research literature highlights different factors facilitating or hindering recruitment and retention of health care workers to remote and rural areas, however there are few practical tools to guide local health care organizations in their recruitment and retention struggles.

The most notable research is summarized in a report published by the European Union Northern Periphery Programme (NPP) titled, “Making it Work: Framework for Remote Rural Workforce Stability”. The project was an international collaboration of researchers in partnership with governments from Scotland, Sweden, Greenland, Iceland, Ireland, Norway, and Canada. It identified challenges, developed solutions, and tested pilot projects for recruiting and retaining health professionals in rural and remote areas. The researchers focused on three strategic tasks: [10, 11]

• Planning activities to ensure that the population’s needs are periodically assessed, that the right service model is in place, and that the right recruits are targeted.
• Recruitment activities to provide the information and support needed to relocate and integrate in the local community.
• Retention activities to support team cohesion, train current and future professionals for rural and remote health careers, and assure the attractiveness of these careers.

They also identified five factors for success including: recognition of unique issues; targeted investment; a regular cycle of activities involving key agencies; monitoring, evaluating, and adjusting; and active community participation [10]. The report is a useful guide for the development of remote and rural health policies in Canada.

Several other research groups have offered additional solutions and unique perspectives. The Rural Road Map (RRM) Implementation Committee reported that rural populations continue to have non-equitable access to healthcare services [19]. The RRM supports a shared solution process centered on four policy goals:

• Establish government and university partnerships with rural physicians, rural communities, and regional health authorities to strengthen the delivery of medical education in rural communities (Federal, Provincial, Territorial government)
• Establish programs with targeted funding to enable rural family physicians to obtain additional or enhanced skills training (Federal, Provincial, Territorial government)
• Establish contracts for residents working in rural settings that maximize their clinical and educational experiences without compromising patient care or the residents’ rights in their collective agreements (CFPC)
• Establish a Canadian rural medicine service to enable the creation of a special national locum license designation (FMRAC, CMA, RCPSC, CFPC)

The Canadian Medical Association policy paper “Ensuring Equitable Access to Care: Strategies for Governments, Health System Planners, and the Medical Profession” provided recommendations for national initiatives to support rural healthcare access (Table 8, 9) [102]. An additional Canadian Medical Association paper “Health Equity and the Social Determinants of Health” highlighting the evidence that people living in a rural location have social determinants that impact their health status. Healthcare access has important outcomes related to personal health-related screening, diagnosis, and acute or chronic condition or disease management [103].

Other researchers have suggested that to achieve human resource sustainability, rural and remote healthcare services require service models that are designed in and for the location and respect the needs of the local population [104]. Important factors for a successful primary care workforce program for recruitment and retention require:

• an offering of ‘turnkey’ clinical work with a functional EMR, ongoing collaborations and partnerships.
• communication technology supporting quality and effectiveness
• specialist care access in a supportive culture for the local primary care providers
• an understanding of recent medical graduates who bring a different life experience and work expectations than older established medical providers

A Pipeline model for rural physician training and retention should include pre-medical rural initiatives/rural mentorship, directed rural medical school experience, residency training, specific practice/other support (incentives, locums, family-spousal opportunity, rural economy factors, and specific community needs [105]. Funded and academic educational connections are paramount for this pipeline model as rural sites often have limited resources, support, and coordination from higher organizational levels for implementation of these steps continues to be challenge [106].  The ‘larger’ pipeline model must include community, university, rural healthcare professionals/teams, health and education administrators, and policy makers (federal, provincial, territorial, and regional) and use the process of social accountability [105]. USA rural healthcare delivery locations strongly support the need for healthcare science education including the business of medicine (operations, managerial accounting, finance, negotiations, e-health, policy-advocacy, and entrepreneurship/innovation [107].

All healthcare providers are required to update and maintain necessary clinical, maternity care and surgical skills through CME and self-life-long learning pathways [69]. Mechanisms for quality and safety improvement such as audit and feedback comparisons with colleagues must be in place at all levels of birthing facilities [22, 108-110]. Ongoing quality improvement and education programs associated with team building initiatives are essential in each institution to evaluate:

• new clinical care models [111]
• site-based rural practice education [64, 65, 112]
• electronic and Virtual Care [113, 114]
• the response-to arrival time and decision-to-incision time protocols and their capacity to effectively respond to emergencies [22]
• measuring quality of care in obstetrics [115, 116]
• drug pricing and availability [117]

Discussion

The disconnect between federal-provincial healthcare planning activity, regarding rural communities and providers policy interventions, highlights the provincial political short-term (3-5 years) focus on a healthcare service process that requires a long-term solution (20-30 years). The Canadian Healthcare System, with 14 provincial and territorial administrations, are a direct obstacle to appropriate long-term healthcare innovation and planning as the provincial political healthcare leadership has, over the last three decades, not been able to make any required long-term fiscal healthcare commitments to allow for rural healthcare success and sustainability [21]. The process for the political – administrative healthcare leadership to prioritize rural obstetric and surgery healthcare services requires an effective advocacy approach [118]:

• the healthcare concern is appropriate and requires timely concern
• appropriate scoping review methodology has been used with no conflict of interest
• the data from peer-reviewed and ‘grey’ publications provides an informed perspective using reliable and best available evidence
• appropriate strategies, suggestions, options, and considerations are provided in a understandable and constructive format
• this long standing rural obstetric and surgical service gap is complex and multifaceted and affects 20% of Canadians but has a major impact for pregnant people’s reproductive experiences

Focused Canadian rural healthcare population needs have been well studied and described but commitment by federal-provincial political healthcare leadership is limited.

The CMA Position Statement on ‘Ensuring Equitable Access to Care: Strategies for Governments, Health System Planners, and the Medical Profession’ reports, that despite a commitment to equal access to health care for all Canadians, there are major differences in access and quality of care for many groups including the most vulnerable (rural populations) (Table 8 [102]). Rural populations, who live near provincial borders, are further burdened as their access to scheduled surgical services are denied in the non-resident   province.  This restricted access for elective hospital services is documented for British Columbia -Alberta and Quebec-Ontario border patients by the Alberta and Ontario health services. The CMA Policy for Health Equity and the Social Determinants of Health: A Role for the Medical Profession reports on Clinical Practice, with several recommendations that should have enhanced the rural health process indicate that the implementation has been limited due to the variable provincial healthcare priorities [103]:

• Collaborative team-based practice be supported and encouraged.
• Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify.
• All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician

The CIHI Rural Health Service Decision Guide provides a useful ‘planning road map’ for rural health care business planning though: validation and quantification of the population need and demand for a service; identification of potential service delivery options; assessment of each viable option thoroughly and systematically; and consideration of important facets of service delivery and sustainability when making a decision. The decision-making process will help to assess /create a proposal to implement a service change (adding a new service, eliminating a service, reconfiguring an existing service); to explain a decision to local residents, service providers or politicians, using objective facts and evidence; or to assess a decision that’s already been made and determine whether further changes are warranted [4].

Service models have been proposed such as the Canadian Institute for Health Information ‘Rural Health Service Decision Guide’ [4] and the European international collaboration (Scotland, Sweden, Greenland, Iceland, Norway, and Canada) ‘Making It Work’ [11] (Figure 1). The Making it Work: Framework for Remote Rural Workforce Stability describes the range of initiatives that need to be considered as an integrated suite of interventions, for any government or healthcare system organizations to effectively establish and maintain a stable workforce in rural and remote communities [11]. Canada collaborated with other Northern located countries, while provincial healthcare providers were not included this EU funded process.  The ‘Making It Work’ themes and findings could be transferable to rural health planning in Canada. Five conditions for success are recognition of the unique rural and remote issues, inclusion of rural and remote engagement and perspectives, adequate investment, annual cycles of activities, and monitoring and evaluation. Remote rural service providers and the authorities that support them, must develop a long -range plan that ensures workforce sustainability [11]. There is overwhelming evidence that supports a significant return on investment when educating and training rural and remote residents to become the future professionals needed for service delivery in these regions. The need for this ‘investment’ may be the most important long-term strategy in workforce sustainability. While taking the long-range view is essential to build the local pool of qualified employees and professionals, it is also essential to invest in attracting and retaining people from elsewhere and creating an environment where they will live and work [64-66].

The creation of policy, position statements, and evidence of healthcare service ‘gaps’ continue to identify need, but they have not activated healthcare rural service prioritization. Healthcare audit for urban- rural obstetric and surgery services including systematic review highlight important total service gaps and adverse events [29, 30, 46, 57, 94, 109, 110]. Rural hospital services are limited in their ability for quality improvement activity due to human resources and funding.

The rural healthcare obstetric and surgery service planning requires the inclusion of healthcare service quality specific principles: population health need; shared responsibility; flexibility and innovation; team-based approaches; close to home with cultural safety. A 2018 report published by the Healthcare Insurance Reciprocal of Canada and the Canadian Medical Protective Association suggested that quality improvement which is focused on the obstetrical care with purpose (improve, empower, focus) and use of key team-based themes (addressing system issues, adopting human factor strategies, strengthening team communication, enhancing provider clinical decision making) is required [44]. Recommendations from a National Panel on Quality Improvement in Obstetrics’ focused on collaborative care -team requirements (knowledge gaps; promising interventions; barriers to spread; opportunities for spread) with 12 high-risk opportunities for improvement [97] (Table 6 [97, 98]). Other collaborative activities emphasize the QI value (Table 7 [99-101]).

Quality improvement knowledge can be used and introduced into the primary rural and remote planning processes by providers and policy makers. A systematic review for quality improvement initiatives identifies the areas of obstetrical care practice with high medical-legal risk [107]. For this review, the identified factors affecting collaborative care are important to consider. The reported process-of-care indicators are interprofessional huddles, documented structured handover, protocol for shared care, transfer of care, missing care related information, and review of care deviation (identified by patient, manager, or delayed care review). The identification and implementation of these quality improvement initiatives depend on institutional alignment and the key facilitators for change [119].

National family physician and obstetrical provider opinions are provided with  Rural Road Map  actions responding to the broad needs of rural healthcare (social accountability; best practice models; rural research) [19], Provider Consensus (Family, Obstetric, Surgery, Anesthesia, Emergency Medicine) for rural anesthesia, surgery, obstetric care requires clinical coaching, CME, and QI activities {20], the Western Canadian White Paper focused on the collaborative value for the obstetrical and surgical regional-based synergy [17], National Academic Societies SOGC Guideline Rural Maternity Care consensus evidenced-based recommendations [18] and Joint Position Paper for rural surgery and operative delivery using a network model of care [14] . The key point, from all these rural provider-based opinion sources, is to create an ‘integrated interprofessional rural health service delivery network(s) that can deliver optimal care to rural residents, while improving both patient and provider experience and satisfaction, within a cost-effective framework’.

British Columbia, Alberta, and Ontario have focused limited areas of high-quality rural healthcare. The British Columbia rural and remote obstetric and surgery healthcare ‘plan, recruit, and retain’ process should include the use of Triple Aim Goals which include improving population health, the patient experience of care, and reducing per capita cost of health by focusing on quality [48]. Alberta has formalized a rural surgical and obstetrical network, using clinical streams such as residency training program, advocacy for standardization of privileging pathway, CME support, coaching program, continuous quality improvement and related research, and an organization and financial framework [56]. Ontario has supported the rural health hub framework (planning, funding, delivery) integrating services across health sectors at the local or multi-community level and broader services if feasible [59].

The primary skill-set training required for rural maternity services for all team members will vary but should include appropriate competencies such as interprofessional work and collaborative practice. Focused residency, midwifery, nursing training will assist in the transition to rural maternity care locations. Access to additional training in advanced skills may include caesarean delivery, obstetrical anesthesia, and neonatal care is an important option. These options are available through university and directed-mentoring programs [18].

There is both a shortage and maldistribution of the physician supply which impacts the rural physician supply and retention in Canada. These factors are due to prior reductions of medical school opportunity, increased competition for international medical graduates in urban centers, longer postgraduate training times, and migration from rural to more urban areas [95].

The influential factors that lead to physician turnover in rural communities are complex but require an understanding for rural context: personal challenges (partner career; extended family; life plan; community integration), professional support affecting retention (lack of resources, team dynamics, contract), professional experience affecting retention (burnout; service demand; responsibility), rural community lifestyle affecting retention (lack of opportunities and amenities; patient expectations; dual roles; personal privacy; status; travel), and association with academic institution (impact; presence; ease of engagement). The ‘double-edged sword’ for rural providers (positive/negative factors) was an important acknowledgement for this qualitative interview process [63].

There are selected rural populations that require prioritization and important collaborative cultural planning. Rural indigenous heath has a long history of public and medical misconception including racialization, there is the need for ongoing cultural and social understanding, as well as professional training regarding the human biological variation and disease association impact.  Achieving progress in these clinical areas of care and access for all rural and remote patients will require important system changes and consent including an understanding of the cultural beliefs and values may introduce bias; rural data collection and review; the types and sources of health data that will need to be re-considered allowing wider views for better understanding of the disease processes;  the importance of multiple data sources (public health, medicine, economics, behavioral science) allowing new input from sources not previously involved in ‘healthcare research’ [120, 121].

An Alberta cohort study evaluated people with First Nation status and their emergency department triage scores. The First Nation status was associated with lower odds of receiving higher acuity triage scores (all 5 disease categories and 3 of 5 diagnoses categories) compared with non-First Nation patients in adjusted models. These findings were interpreted to possibly indicate systematic racism [122].

The rural hospital (USA) obstetrical services have indicated similar healthcare challenges to rural Canada. Obstetrical emergencies in USA rural hospitals, with no obstetrical services, were surveyed with completed reports from 69 of 144 rural hospitals. Common emergency care concerns were lack of specialty care, lack of skills to address emergency birth, and insufficient medical equipment and supplies. Increased education (CME and family practice residency) was identified to better avoid or address close calls or adverse birth outcomes and to improve skills. Better service planning coordination between USA rural hospitals with and without obstetrical services is required [123]. The loss of hospital-based obstetrical services in rural USA counties showed a greater proportion in micropolitan rural counties (towns with population of 10,000) have and retained obstetrical services but low populated rural counties near to larger urban areas were least likely to have continued local obstetrical services. [124]. A planning process for rural health service integration was recommended for consideration by healthcare policymakers to [125]:

• have a clear differentiation of rural and urban hospital services especially when they are in a single healthcare system
• consider reviewing the rural hospital healthcare service impact when obstetric or surgical service consolidation is being considered
• assess the negative impacts of proposed cost-saving activity on essential rural services
• explore a policy that gives communities more input into the healthcare decisions being made about their rural healthcare services

A directed federal-provincial process, possibly via rural healthcare transfer payments, is required as the functional rural clinical networks must be created and in place for the long-term success of rural obstetrics and surgery care needs: equitable, supportive, and sustainable health care provider agreements with directed but necessary redundant human resource requirements; rural patient focused access and quality care; and clear political – clinical care policy.

A national federal-provincial-provider directed Royal Commission to consider and evaluate the question ‘Is it time to consider a national or collaborative regional approach to Canadian health care delivery and human resource management? This consideration could start with a federal-provincial collaborative model using a regional population-based (2020) allocation (Western (BC, Alberta, Saskatchewan, Manitoba, Yukon, NWT, Nunavut) 12,349,186 population, Ontario 14,826,276 population, Quebec/Atlantic (NS, PEI, NB, NFLD) 11,070,646 population) [126]. These three-population balanced geographic regions could be considered after important federal-provincial political discussion.

It is time to think about ‘big change’ to provide improved access, better health outcomes, and more cost- effective health care for Canadian patients and providers?

Conclusion

Recognition of a significant healthcare gap (rural and remote obstetric and surgery access and provision) and the prioritization of healthcare services by objective rather than reactionary criteria (vulnerable populations) is required for rural obstetric and surgery access and service sustainability. A national or regional collaborative network process that emphasizes the need for long-term vision, planning, and sustained funding can consider key strategic and thematic elements:

• Plan: activities that may be taken at a local, regional or national level to ensure the population’s needs are periodically assessed, and that the right service model is in place, and that the right recruits are targeted.
• Recruit: generally led by the local and/or agency level to ensure that the right recruits have the information and support needed to make the life decision to relocate to the community and that when they arrive, they and their families are integrated and welcomed in the community.
• Retain: the support needed to train current and future professionals appropriately for rural and remote health careers and that career options in these settings are viewed as positive.

Obstetric and surgical networks require stakeholder trust; resources; culture of safety, collaboration, respectful teamwork; leadership; formal organization; clear and explicit service agreement, mentoring; CME; inclusive interactions with patient, community, and health authorities; clear sustainability for small hospital maternity and surgical services, fiscal support, and human resources management.

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