It’s not easy being a pregnant woman in rural British Columbia. With 10–20% annual attrition of family physicians in rural BC, and 17 rural hospitals having ceased maternity care services since 2000, many women lose the ability to deliver in their own community even if local hospitals exist. What are the causes and consequences? We investigated rural maternity care from the perspective of parturient women and care providers. Through a series of interviews and focus groups in 14 communities across BC, we learned about the current state of maternity care in rural BC and investigated how the reduction in maternity care services has impacted women’s lives, physician’s confidence, and community ethos.

Background: Rural maternity care in Canada is in crisis, with many communities losing local services. This forces rural women and families to travel for care, leading to heightened stress, expenses, and adverse outcomes. Family physicians, often the primary providers of rural maternity care, are decreasing in numbers, exacerbating the problem. Without enough providers, rural communities struggle to offer safe and accessible maternity services, risking the health of expectant mothers and families. Objective: This research aims to gain a comprehensive understanding of the socio-ecological influences that shape the commitment of family physicians and residents to practice rural maternity care. Methods: A scoping review was conducted, and database searching occurred in Ovid Medline, Ovid Embase, Ovid Emcare, and Web of Science. Primary studies and literature reviews in English were included if they discussed family physicians' and residents' experiences and perspectives in practicing and training for rural maternity care. Articles were restricted to the past 30 years. Thematic analysis was applied to analyze the data, and results were reported in tabular format. Results: Influencing factors were categorized into themes and contextualized across the socio-ecological model: 1) individual factors (i.e. interests, attitudes, motivation, burnout, risk), 2) interpersonal factors (i.e. lifestyle, interprofessional relationships, mentors), 3) organizational factors (i.e. training and professional development, work environment and practice characteristics, resources, regulation and privileging), 4) community-level factors (i.e. practice setting and location, job availability, community context), and 5) systematic factors (healthcare system structure, public policy, legal and regulatory framework). Conclusion: The most salient influencing factors included challenges with Family Medicine residency training and role models, call schedule sustainability and interprofessional collaboration, as well as preserving clinical skills and financial stability with low procedural volume in rural communities. There is a need to implement evidence-based interventions targeting training, recruiting role models, interprofessional collaboration and call, and effective rural remuneration. / Thesis / Master of Science (MSc) / Family physicians (FP) are often the sole care providers of maternity care (MC) in rural communities. Unfortunately, there is a declining number of FPs choosing to provide comprehensive maternity care (CMC). In addition, centralization has resulted in rural maternity center closures across the country. Rural women and families that must travel to access MC experience increased levels of stress, personal costs, and increased rates of adverse outcomes. With fewer FPs available to provide CMC alongside maternity centre closures, rural communities face challenges in ensuring safe and accessible care for expectant mothers. Addressing this issue is vital to protecting the health and well-being of rural families. Although research exists regarding the challenges FPs encounter when providing CMC in rural areas and what influences resident practice intentions, there has yet to be a synthesis of the literature over the last 30 years. To address this, a scoping review was conducted to explore the research on the influences on FPs’ and residents’ commitment to practicing rural MC. This scoping review can help understand what factors have been most influential over time, emerging challenges, and what socio-ecological levels to target for intervention.

Background: This research explores whether rural Community Maternity Units (CMUs) contribute to NHS Scotland’s Quality Ambitions of safe, effective and person centred care. Currently there is no available recent evidence regarding the quality of this particular model of care in a rural setting. This research makes an important contribution given that most women are encouraged to access local maternity services. Design: An exploratory case study was used with a hermeneutic phenomenological approach to the qualitative data collection and analysis. Quantitiative data were collected and analysed to provide descriptive statistics. Methods: The study was conducted in three phases. In phase one a retrospective medical records review was undertaken to provide quantitative data on the care provided. Phase two was an observation of team meetings, interviews with staff and focus groups with stakeholders in roles aligned to the provision of care at the CMUs. In phase three observations of clinical encounters and interviews with women informed by aide memoire diaries were used. Findings: Maternity services provided by the CMU teams achieved a consistently high standard of safety and effectiveness when measured against national guidelines, standards and other evidence. The stakeholders appreciated the ability within these small teams to provide local, accessible services to women with effective support when required from tertiary services. The women valued person centred and relationship based continuity of antenatal carer, provided by compassionate named midwives, but were disappointed by the discontinuity when complications occurred. Conclusions: The CMUs’ physical position within the community, smallness of scale and the midwifery team’s ethos of normality within a socially based but medically inclusive service facilitated local access for most women to maternity care. This service provision addressed NHS Scotland’s Healthcare Quality Strategy of improving health and reducing inequalities for the people of Scotland. The role of the named midwife was key to providing high quality care by maintaining connections across contextual boundaries for women experiencing normal and complicated pregnancies. This research provides an original contribution to the study of rural maternity service provision in Scotland to help inform future sustainability and service development of rural CMUs.