Models of maternity care in rural environments: Barriers and attributes of interprofessional collaboration with midwives
Introduction
Throughout the last century, the primary maternity care needs of women in Canada have been met by family physicians and specialists (Blais et al., 1999, Collin et al., 2000) with support from nurses (MacKinnon et al., 2005, Medves and Davies, 2005). In recent years, an increasing proportion of parturient women have sought care from midwives, who are regulated and publicly funded in all but two provinces and one territory, Newfoundland, Prince Edward Island, and Yukon Territory (Canadian Association of Midwives, 2011). In parts of rural Canada the local care of parturient women is undertaken almost exclusively by family physicians with the support of specialists in referral communities (Iglesias and Hutten-Czapski, 1999, Kornelsen and Grzybowski, 2010). However, we are experiencing a health human resource crisis in rural – and urban – maternity care due to a confluence of challenges including shortages in obstetrically trained nurses and the growing attrition of family physicians from rural practice.
Interprofessional primary maternity care – where providers work together to meet the needs of birthing women – has emerged as one potential solution to this situation. However, there are significant barriers to such collaboration given the disciplinary differences between the groups such as scope of practice, professional orientation, and funding models. In geographically isolated rural communities, challenges are exacerbated by the unique context of small birthing populations and limited hospital resources. This has been demonstrated in rural British Columbia where low volume and professional isolation have contributed to the limited integration of midwives into rural practice (Centre for Rural Health Research, 2008a, Centre for Rural Health Research, 2008b, Centre for Rural Health Research, 2011). While interprofessional maternity care models are beginning to emerge in urban environments, barriers specific to rural communities exist but are not well understood within the context of policy and planning. In order for policy makers and planners to promote and support sustainable models of team-based rural maternity care, evidence on the attributes of interprofessional collaboration in a rural context is necessary.
This study explores the barriers to and facilitators of interprofessional models of maternity care between physicians, nurses, and midwives in rural British Columbia, Canada, and the changes that need to occur to facilitate such models. Findings are discussed within the context of ongoing legislative and regulatory, legal and financial, and professional (ideological) barriers to interprofessional care.
In comparison to other developed countries, midwifery in Canada plays a relatively small role in the provision of maternity care. There are 846 registered practicing midwives in Canada, of which 157 practice in British Columbia, the western-most province (Canadian Association of Midwives, 2011). Currently, BC Midwives provide care for approximately 10 per cent of the 43,000 annual deliveries and have been publicly funded and regulated since 1998. Similar to models in the Netherlands, New Zealand, and United Kingdom, Canadian midwives are autonomous, community-based care providers and work in solo or small group practice. In rural British Columbia, the consumer demand for midwives has increased steadily since provincial regulation, particularly in rural and remote communities where the midwifery model is well suited to meet the needs of socio-economically vulnerable women, including First Nations women.
In recent years, efforts toward increasing the sustainability of maternity care in Canada have included the exploration of interprofessional models of care. At a national level, this has been led primarily through the Multidisciplinary Collaborative Primary Maternity Care Project (MCP2), a Health Canada funded, joint initiative of all key Canadian maternity care provider organizations, designed to facilitate collaborative primary maternity care strategies as a means of increasing the availability and quality of maternity services for all Canadian women (MCP2, 2006). Directly building on the recommendations of MCP2, the Society of Obstetricians and Gynecologists of Canada (SOGC) published a National Birthing Initiative (NBI) in 2008, highlighting the importance of addressing key barriers to interprofessional collaboration (Society of Obstetricians and Gynaecologists of Canada, 2008). In addition to interpersonal challenges, the NBI recognized the barriers posed by the health-care system, such as different professions' scope of practice and the lack of financial models to support interprofessional collaboration. At a provincial level, the push towards interprofessional models of maternity care is reflected in initiatives such as the Ontario ‘Babies Can't Wait’ project (Kasperski et al., 2006) and the Aboriginal birthing programme in Nunavik, Quebec (Van Wagner et al., 2007). In British Columbia, the ‘Maternity Care Enhancement Project’ recommended the promotion and support of women-centred, collaborative, team-based models of maternity care as a solution to the province's physician resource crisis (Maternity Care Enhancement Project, 2004). Despite this the rhetoric supporting interprofessional collaboration for maternity care, collaboration with midwives in Canada has been slow and fraught with challenges (Kornelsen, 2009). In the context of rural British Columbia, systemic barriers to interprofessional collaboration have included historical resistance to homebirth on the part of the College of Physicians and Surgeons of BC which has hindered the uptake of collaborative relationships.1 Critics have argued persuasively for and against interprofessional collaboration in Canadian rural maternity care, with proponents pointing to the benefits to physicians of integrating more care providers into a rural community's on-call schedule (Rogers, 2003) and opponents arguing that midwifery practice is unsustainable in low-volume environments (Hutten-Czapski, 2003).
To date, there have been studies examining the qualities of interprofessional collaboration between midwives and nurses (Kornelsen et al., 2003, Kennedy and Lyndon, 2008, Bell, 2010) and the attitudes and beliefs of professional leaders (Peterson et al., 2007). Findings from the latter study indicated that representatives from the national maternity professional associations anticipated that collaborative maternity care could help mitigate work/life challenges that were contributing to the current health human resource crisis in maternity care. Others predicted benefits of collaborative care included improved access to care, choice of care provider, and appropriateness of care provider for birthing women. However, the participants also expressed concerns about how interprofessional models of maternity care could be implemented given current incompatible fee structures between the professions, issues with team insurance coverage, and interdisciplinary rivalry.
Drawing from the definition of multidisciplinary care found in MCP2, we interpret interprofessional collaboration to mean collaboration between maternity care providers built on mutual respect, trust, and flexible competency-based definitions of care provider roles and responsibilities (MCP2, 2006). Further, in successful interprofessional collaboration, care providers’ skills sets and scopes of practice were recognized as complementary and differences in roles were respected.
Section snippets
Methods
A qualitative, exploratory framework guided the data collection and analysis, an approach used when there is an overall lack of developed knowledge about an issue or problem (Strauss and Corbin, 1998). We used extreme case sampling to select research communities using the following sample criteria: (1) communities that currently provide maternity care services or have the potential to offer such services; and (2) communities with the presence of primary care providers (general practitioners,
Findings
In total, 55 participants were interviewed and 18 focus groups were conducted in four rural BC communities (see Table 1). Each of the four communities studied exemplified a different model of interprofessional collaboration, ranging from independent, parallel community-based practice between midwives and physicians to integrated care involving a shared on-call schedule and patient caseload. Two communities were in the process of integrating their first local midwifery practices (Communities A
Discussion
Participants in this study indicated that interprofessional collaboration between midwives and other primary care providers is a complex and synergistic process. While in most cases participants were eager to improve interprofessional relations, many expressed that they were unsure of how to facilitate collaboration, particularly in the face of systemic restrictions imposed by financial, legal, and regulatory structures. For participants navigating interprofessional collaboration in a complex
Acknowledgements
The authors gratefully acknowledge funding through the Canadian Institutes of Health Research. We also thank our study participants for sharing their stories and project co-ordinators Melanie McDonald and Shelagh Levangie for their invaluable research support.
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