Midwifery care in rural and remote British Columbia: a retrospective cohort study of perinatal outcomes of rural parturient women with a midwife involved in their care, 2003 to 2008.

INTRODUCTION: Midwifery has been regulated and publicly funded in British Columbia since 1998. Midwives are currently concentrated in urban areas; access to care is limited in rural communities. Rural midwifery practice can be challenging because of low birth numbers, solo practice, lack of on-site cesareans and specialist backup, and interprofessional tensions resulting from the integration of midwives into rural maternity care systems. Despite these barriers, rural midwives have made a substantial contribution to rural maternity care in British Columbia. The purpose of this retrospective cohort study is to examine outcomes of midwife-involved births in rural British Columbia in the postregionalization era.

METHODS: We analyzed the outcomes of all parturient women with postal codes outside of the core urban areas of the province, and their singleton infants without a diagnosed congenital anomaly, who had a midwife involved in their care between April 1, 2003, and March 31, 2008. Outcomes are reported for 6 obstetric service levels. Service levels are assigned to parturient women via maternal postal codes. Women who reside further than 60 minutes from a hospital with maternity services were assigned a distance category (2 levels: >2 hours, 1-2 hours); women residing within one hour of a hospital with maternity services were assigned the level of service available at their catchment hospital (4 levels, ranging from maternity care without cesarean to cesarean provided by general surgeons or obstetricians).

RESULTS: Eight percent of rural parturient women had a midwife involved in their care. Rates of planned home birth exceeded the provincial average (26.1%) in 5 of the 6 service levels. Rates of actual home birth were lowest among women who resided 2 or more hours away from maternity services. Obstetric intervention rates were lower for women residing in communities without cesareans or with intermittent access to cesareans. The prevalence of adverse neonatal outcomes was very low across service levels; perinatal mortality was elevated among women residing in communities more than 2 hours away from services.

DISCUSSION: Despite numerous challenges, midwives provide safe maternity care to rural parturient women and offer choice of birth place. Given the difficulty of recruiting and retaining maternity care providers to rural settings in British Columbia and across Canada, these findings open the door for a more sustained planning process involving midwives in rural communities. Reasons for the elevated perinatal mortality rate among women who live more than 2 hours away from services should be explored in more detail, perhaps via in-depth interviews with rural midwives who serve this population.