A February 20, 2018 CBC News article by Briar Stewart, a senior reporter based in Vancouver for CBC News, reports on the challenges for pregnant women in Fort Nelson, a community of 3,500 in northern B.C., where part of the prenatal routine includes agreeing not to have their babies locally. 

A memo from the health centre under the heading Re: Permanent Discontinuation of Maternity Services in Fort Nelson, outlines the difficulty, “Due to staffing issues, we are unable to conduct safe obstetric care in Fort Nelson.  Under these circumstances, we advise clients to be delivered in different facilities where they can have their babies safely.  During these periods, it may mean those pregnant women of 36-38 weeks of gestation going to alternative places of delivery.  We do hope this period provides clients adequate time to implement the necessary plans to go to the alternative facilities of delivery.  Please note the service of emergency air medi-vacing patients is unreliable for a variety of reasons.  For Safety reasons, it would be better to plan for these circumstances ahead of time as suggested above.”

 Briar Stewart interviewed an official from Northern Health, which oversees health centres in the region, who stated that, while physicians and staff are equipped to respond to an “unplanned delivery”, women are advised to leave up to a month before their due date, because “the safety of both the mother and the baby must come first.”

Pregnant women in the area are asked to sign the memo to acknowledge their awareness of the situation and that they should make arrangements to deliver elsewhere.  The next closest hospital is in Fort St John, 380 kilometres away.

Stewart reports that Fort Nelson “is one of dozens of rural communities in Canada where maternity services have been eliminated, in part because of the ongoing struggle to recruit and retain doctors in remote parts of the country.”  This issue was referenced previously in the February 27, 2017 Keeping in Touch article on Tofino-Ucluelet CPNP.  As well as the issues of caring for older children in the family during the time their mother has to be away, and of maintaining connection and support between partners and with extended family members during the period surrounding the birth of a new child in the family, the financial costs of leaving community for an extended period around the birth can pose a great burden, especially if there are any complications with the birth that require the mother and infant to stay close to medical care for a longer period after the baby is born.

Lack of medical support also impacts decision-making around family planning, with some families choosing to have fewer children as a result.  For rural areas that can be struggling to maintain population numbers, this is a significant issue.

A 2013 paper by the Canadian Foundation for Healthcare Improvement outlines the difficulties of accessing medical support for residents of rural communities:

If you are one of the many Canadians without a family doctor, you know how challenging a problem this can be. For Canadians in rural and remote areas, this problem is especially serious. Most rural and remote communities face a shortage of health workers, especially doctors. Although rural Canadians constitute 22% of the population, fewer than 10% of physicians and 2% of specialists work in these areas. While Canada as a whole averages one doctor per approximately 450 residents, this ratio can be as low as one in 3,000 in some remote areas. Adding to this problem, residents of rural and remote communities often have greater healthcare needs than urban residents, experiencing higher rates of chronic disease, traumatic accidents, and poorer mental health than their urban counterparts.

International recruiting has been used to help address the shortage of rural physicians.  Currently, this is done primarily through granting provisional licenses to internationally educated physicians or issuing Return of Service agreements.  “In both cases, international medical graduates agree to work in an underserviced area for a number of years before receiving full licenses to practice medicine in Canada.”  Unfortunately, this has not had the desired effects of building up long-term service for rural areas.  After international medical graduates receive their full licenses or complete return of service agreements they are free to practice anywhere in Canada, with most either moving to urban areas to practice or moving on to other careers.  A 2009 study showed that only 40% of those licensed under provisional licenses between 2002 and 2006 could still be found on the Canadian Medical Directory (Audas & Vardy, 2009).

The authors of the discussion paper note:

Several barriers contribute to the difficulty rural and remote areas have in retaining physicians, including a heavy workload, professional isolation, and limited career options. Personal considerations are also important obstacles, including fewer educational opportunities for children, and limited cultural and religious resources. Employment and social opportunities available for spouses may also be inadequate, further hindering long-term retention in remote areas.

The paper concludes that the reliance on international recruiting has not served the long-term needs of rural communities, as “the biggest obstacle to maintaining sufficient health staff in remote areas is not recruitment, but rather retention. Evidence suggests that the most reliable way to attract and retain rural physicians is to recruit rural applicants into medical schools and to provide extended exposure to the special challenges of rural practice during training.”  This argument is strongly supported by the College of Family Physicians of Canada in a January 2016 background paper, Review of Family Medicine Within Rural and Remote Canada:  Education, Practice, and Policy. 

 The background paper notes: “Evidence has shown that countries that have strong primary care systems that enable their populations to have access to primary care have better health outcomes. Access to primary care, as one of the key indicators of quality health care, remains an issue in rural and remote Canada. As such, it has been identified as a top priority for health system reform.”  The authors acknowledge that strides have been made since 1999, with “increased numbers of graduating rural physicians, increases in exposure to rural training in all undergraduate and postgraduate programs in Canada, and the development of rural-specific streams for training in family medicine”. However, the numbers of physicians graduating with expertise in providing medical support to rural communities is still far from meeting the need.

Specific strategies recommended include:

• Integrating rural medicine into medical school curricula
• Providing positive rural learning experiences for medical students
• Providing specific rural residency training for rural family medical practice
• Connecting education to recruitment and retention processes in rural communities
• Increasing the provision of rural clinical teaching sites in the training of physicians across Canada

Four factors have been identified as associated with an increase in the probability of physicians choosing to practise in rural and remote communities:

• Rural upbringing
• Positive undergraduate rural exposure
• Targeted postgraduate exposure outside urban areas
• Stated intent/preference for general or family practice primary care

Several universities, including the Northern Ontario School of Medicine, Memorial University, and Queen’s University have been involved in developing an intentional and longitudinal approach to rural education referred to as the ‘rural physician workforce pipeline’.  Despite the success of this model, the background paper states that, unfortunately, “a consistent and replicable approach has not been adopted across Canada”.  The paper recommends “a coordinated approach involving evidence-based physician resource planning at the national and provincial levels to provide direction to the medical education system”.

A May 18, 2017 CBC article on graduates of University of Manitoba’s largest-ever class of doctors highlights the issues.  Only 12 of the 113 graduates planned to do their residencies in rural Manitoba.  The article interviews one of the new physicians who grew up in a rural area and was planning to do a rural practice residency.  She speaks eloquently to the challenges facing rural communities in accessing medical care.  http://www.cbc.ca/news/canada/manitoba/doctors-from-largest-uofm-grad-class-hope-to-help-chronic-rural-doctor-shortages-1.4122357

Looking at the situation in B.C., Briar Stewart interviewed Jude Kornelsen, of the University of British Columbia, who has done extensive research on access to maternity care in rural B.C. and says more than 20 communities in the province have had their services cut since 2000.  She says the same trend is playing out across the country, forcing more women to travel farther away to deliver.

A study by Kornelsen and her colleagues published in 2011 found:

• The infant mortality rate is three times higher for women who have to travel more than four hours to deliver.
• There was a higher rate of preterm births and babies with low birth weights for women who drove more than two hours.

Kornelsen says even driving one hour away can be risky because women often don't leave for the hospital until they are already in labour. 

Kornelsen says a "culture of risk aversion" has convinced some women they should only give birth in fully equipped hospitals capable of performing a C-section if required, but that's not necessary in most births.  Most communities can use the midwives and nurses they already have in the area, and that can be supplemented with additional training and better access to emergency transportation.

While it is unrealistic for every very small community to have a dedicated maternity ward, Kornelsen advocates that “where the population level warrants it, the provinces need to do more to bring back services”.