title: Obstetric services in small rural communities: what are the risks to care providers?
abstract: BACKGROUND
  In spite of a sharp decline, since 2000, in the number of rural communities in Canada that offer local maternity care, there remain significant numbers of small rural maternity services that provide elective maternity care without on-site access to cesarean section. In communities with an elective maternity service without local access to surgical capability, practitioners must be prepared to respond to obstetrical emergencies and arrange urgent transfer if a cesarean section is indicated. In most cases reasonably safe care can be provided by this model, but the possibility of an unexpected emergency that threatens the fetus or mother always exists. Although there is an emerging understanding of the stressors faced by rural physicians, little is known about the experience of care providers offering maternity care in low-resourced environments. This article considers the experience of rural maternity care providers from the perspective of the social risks they perceive are incurred by practicing in a low-resource environment.
  
  
  METHODS
  A qualitative exploratory approach was employed, using in-depth interviews and focus groups with care providers in three rural communities in British Columbia, Canada. The transcripts were thematically analyzed in four stages.
  
  
  RESULTS
  Twenty-six care providers were interviewed across the three communities, including 15 nurses and 11 physicians. Participants identified elements of personal risk they perceived were assumed by offering intra-partum care in communities without local access to cesarean section back up, and the potential effects of these risks on themselves and their communities. They further recognized the unique attributes of maternity care, which, when juxtaposed with other aspects of primary care, led to a heightened sense of social risk in a rural environment.
  
  
  CONCLUSIONS
  A balanced approach to risk management grounded in a comprehensive understanding of the values that influence decision-making, including acknowledgement of the social risks care providers incur, is a necessary step towards better health services for rural parturient women and their babies. Additional strategies may include community-based identification of the risks and benefits of local care, and programs of professional support for rural obstetrical care providers experiencing stress.
authors.affiliation: Centre for Rural Health Reserach, Department of Family Practice, West Broadway, Vancouver, BC, Canada. jude@saltspringwireless.com
authors.forename: Jude A
authors.initials: JA
authors.lastname: Kornelsen
authors.forename: Stefan W
authors.initials: SW
authors.lastname: Grzybowski
mesh_terms: D001955:British Columbia; D002055:Burnout, Professional / Q000523:psychology; D003657:Decision Making; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D008427:Maternal Health Services / Q000706:statistics & numerical data* / Q000600:supply & distribution; D024802:Nurse's Role / Q000523:psychology*; D010819:Physician's Role / Q000523:psychology*; D018570:Risk Assessment; D019035:Rural Health Services / Q000706:statistics & numerical data* / Q000600:supply & distribution