title: Key issues and barriers to obstetrical anesthesia care in Ontario community hospitals with fewer than 2,000 deliveries annually.
abstract: OBJECTIVE
  Lack of the availability of anesthesia services may be a factor in the closure of maternity services in rural Canada, limiting the capacity for Cesarean delivery and intensifying the urbanization of maternity care. Unlike other professions involved in maternal newborn care, health services research in obstetrical anesthesia is virtually non-existent. This study explored barriers physicians encountered in providing obstetrical anesthesia care in Ontario community hospitals experiencing low volumes (fewer than 2,000) deliveries per annum (PA). Solutions proposed by a mixed focus group of academic and community hospital leaders were also described.
  
  
  METHODS
  Following Research Ethics Board approval, the authors performed a secondary analysis of qualitative data from 18 anesthesiologists and family practitioner (FP/GP) anesthetists who had participated in a larger provincial study that was also conducted by the authors. Participants were leaders from community hospitals with fewer than 2000 deliveries PA and university-based teaching programs from across Ontario. Fourteen community physicians participated in focus groups that explored key issues and barriers to care and their potential solutions. A final group of eight academic and community physician key informants further explored solutions.
  
  
  RESULTS
  Three themes emerged: Obstetrical Anesthesia in the "Periphery", "Key Issues and Barriers to Obstetrical Anesthesia Care", and "A Multi-faceted but Context-Specific Solution is Required." The physicians identified barriers within the greater context of those encountered during the provision of anesthesia services in the periphery, including lack of time, need for continuing medical education (CME), need for hospital infrastructure support to develop and implement best practice protocols, and need for resources and anesthesia mentorship supports from the system. Difficulties were greatest for FP/GP anesthetists in rural communities who described lack of locums, need for relevant CME, and worsening physician shortages threatening provision of services in some rural hospitals. Family practitioner anesthetist multi-taskers were described as the best solution to the provider shortage in rural communities. Participants described the need for increased numbers of FP/GP anesthetists and the development of formal funded networks for knowledge transfer between academic and community hospitals as a mechanism to provide supports.
  
  
  CONCLUSIONS
  Physicians in community hospitals face significant barriers in the provision of obstetrical anesthesia care. These are greatest among FP/GP anesthetists and in rural hospitals where physician shortages and lack of supports threaten provision of services in some hospitals. Local context-specific and systems-level solutions are required.
authors.affiliation: Department of Anesthesia, Women's College Hospital, 76 Grenville Street, Toronto, ON M5S 1B2, Canada. pamela.angle@sw.ca
authors.forename: Pamela
authors.initials: P
authors.lastname: Angle
authors.forename: Christine
authors.initials: C
authors.lastname: Kurtz Landy
authors.forename: Yamini
authors.initials: Y
authors.lastname: Murthy
authors.forename: Peter
authors.initials: P
authors.lastname: Cino
mesh_terms: D000328:Adult; D000773:Anesthesia, Obstetrical; D000776:Anesthesiology / Q000458:organization & administration; D005194:Family Practice / Q000458:organization & administration; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006764:Hospitals, Community; D006771:Hospitals, Maternity / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D009864:Ontario; D011795:Surveys and Questionnaires; D000078329:Workforce