title: Satisfaction and sustainability: a realist review of decentralized models of perinatal surgery for rural women.
abstract: BACKGROUND
  This article was developed as part of a larger realist review investigating the viability and efficacy of decentralized models of perinatal surgical services for rural women in the context of recent and ongoing service centralization witnessed in many developed nations. The larger realist review was commissioned by the British Columbia Ministry of Health and Perinatal Services of British Columbia, Canada. Findings from that review are addressed in this article specific to the sustainability of rural perinatal surgical sites and the satisfaction of providers that underpins their recruitment to and retention at such sites.
  
  
  METHODS
  A realist method was used in the selection and analysis of literature with the intention to iteratively develop a sophisticated understanding of how perinatal surgical services can best meet the needs of women who live in rural and remote environments. The goal of a realist review is to examine what works for whom under what circumstances and why. The high sensitivity search used language (English) and year (since 1990) limiters in keeping with both a realist and rapid review tradition of using reasoned contextual boundaries. No exclusions were made based on methodology or methodological approach in keeping with a realist review. Databases searched included MEDLINE, PubMed, EBSCO, CINAHL, EBM Reviews, NHS Economic Evaluation Database and PAIS International for literature in December 2013.
  
  
  RESULTS
  Database searching produced 103 included academic articles. A further 59 resources were added through pearling and 13 grey literature reports were added on recommendation from the commissioner. A total of 42 of these 175 articles were included in this article as specific to provider satisfaction and service sustainability. Operative perinatal practice was found to be a lynchpin of sustainable primary and surgical services in rural communities. Rural shortages of providers, including challenges with recruitment and retention, were found to be a complex issue, with scope of practice and contextual support as the key factors. Targeted educational programs, exposure to rural practice and living environments, accessible and appropriate continuing medical education, and strong clinical support (including locum coverage and sustainable on-call schedules) were all found to be areas of important consideration in rural service sustainability.
  
  
  CONCLUSIONS
  Rural practice was found to be a site to actualize personal goals and values for providers. A broad and challenging scope of practice and the opportunity to participate in community level health improvements were seen as critical to the retention of providers. Without proper support, however, providers reported a feeling of being 'in too deep'. Common themes were a lack of health human resource redundancies, compromised access to specialist support and technology, and a lack of work-life balance. Burnout and attrition in perinatal surgical services threaten to destabilize other aspects of rural community health services, making the need to address sustainability of rural providers urgent.
authors.affiliation: Applied Policy Research Unit, University of British Columbia, Vancouver, British Columbia, Canada. jude.kornelsen@familymed.ubc.ca.
authors.forename: Jude
authors.initials: J
authors.lastname: Kornelsen
authors.affiliation: Applied Policy Research Unit, University of British Columbia, Vancouver, British Columbia, Canada. kevin@crhr.ca.
authors.forename: Kevin
authors.initials: K
authors.lastname: McCartney
authors.affiliation: Perinatal Services of British Columbia, Vancouver, British Columbia, Canada. kwilliams6@phsa.ca.
authors.forename: Kim
authors.initials: K
authors.lastname: Williams
mesh_terms: D001955:British Columbia; D003362:Cost-Benefit Analysis; D006280:Health Workforce; D006801:Humans; D007318:Inservice Training; D008427:Maternal Health Services; D008511:Medicine / Q000458:organization & administration; D061214:Patient Safety; D018743:Perinatal Care / Q000458:organization & administration*; D010560:Personnel Selection; D019035:Rural Health Services / Q000458:organization & administration*; D013514:Surgical Procedures, Operative
keywords: General/Family Practice; Health Service reform; Maternal and Child Health; Medical; North America; Obstetrics; Primary Health Care