sement des medecins ont necessitela reorganisation des services obstetricaux ... Manitoulin en Ontario. ... ing, lifestyle issues, and medical-legal fears.3 These.
Dilemma of rural obstetrics One community's solution W.E. Osmun, MD, CCFP Dieter Poenn, MD, CCFP Mary Buie RN, SCM(UK
PROBLEM BEING ADDRESSED Increasing workload and concerns about physician exhaustion necessitated reorganizing the delivery of obstetric services on Manitoulin Island in Ontario. OBJECTIVE OF PROGRAM To organize obstetrics in a remote rural community to provide safe, accessible care, improve working conditions for local physicians, and involve the local hospital and health care workers in the solution. MAIN COMPONENTS OF PROGRAM A prenatal clinic for all obstetric care on the island was established. It was based at the local hospital and organized by a nurse-midwife. Local physicians rotated through the clinic and provided obstetric coverage on their on-call days. CONCLUSIONS The clinic has helped improve working conditions for local physicians and maintain high-quality obstetric care in this remote area. Local women's initial resistance to the clinic seems to be disappearing with time. Ongoing chart audits reveal intervention rates similar to those found in other Canadian studies of rural obstetric care.
PROBLEME DISCUTE L'augmentation de la charge de travail et les preoccupations entourant l'epuisement des medecins ont necessite la reorganisation des services obstetricaux sur l'Ile de Manitoulin en Ontario. OBJECTIF DU PROGRAMME Organiser les services obstetricaux dans une communaute rurale eloignee afin d'offrir des soins accessibles et securitaires, ameliorer les conditions de travail des medecins locaux et impliquer le centre hospitalier local et les travailleurs de la sante dans la recherche d'une solution. PRINCIPALES COMPOSANTES DU PROGRAMME Mise sur pied d'une clinique prenatale couvrant tous les soins obst6tricaux dispenses sur l'Ile. Cette clinique est situee dans le centre hospitalier local et a ete organisee par une infirmiere sage-femme. Les medecins locaux couvrent la clinique 'a tour de role et assurent la couverture des services obstetricaux lorsqu'ils sont de garde. CONCLUSIONS Cette clinique a contribue a ameliorer les conditions de travail des medecins locaux et 'a maintenir des soins obstetricaux de grande qualite dans cette region eloignee. Au debut, les femmes ont manifeste une reticence face 'a la clinique mais cette opposition semble disparaitre avec le temps. Les verifications des dossiers revelent des taux d'intervention semblables 'a ceux qui ont ete observes dans d'autres etudes canadiennes portant sur l'obst6trique en milieu rural.
This article has been peer reviewed. Can Fam Physician 1997;43:1115-1119. -It-
FOR PRESCRIBING INFORMATION SEE PAGE II 55
VOL43: JUNE * JUIN 1997 OCanadian Family Physician. Le Mdecin defamille canadien 1115
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De or l sr Dilemma of rural obstetrics
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n recent years tamily practitioners nave participated in obstetrics less and less,1 and many small obstetric units have closed.2 Various reasons have been cited for abandoning obstetrics: perceived lack of training, lifestyle issues, and medical-legal fears.3 These are valid concerns; however, rural practice has community obligations, and the importance of accessible care to outcomes4'5 makes the decision to continue or abandon obstetrics in a rural context very difficult. This article describes one solution to this dilemma. The medical community in Little Current, Ont, spent much time and effort reorganizing in order to provide adequate obstetric care. We hope that presenting the process, the solution, and the outcome of this reorganization will encourage others to continue providing obstetric services in their communities. I
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I
Problem Manitoulin Island is the largest freshwater island in the world; it is 130km long and up to 60km wide. The island has several small towns and villages but no large urban centre. The closest city is Sudbury, 150km from Little Current. The only land link to the mainland is at Little Current, which is located on the northeastern shore of the island.6 The island's population is 12000: about 35% are First Nation peoples, primarily of the Ojibway nation, and 65% are of European background, predominantly British. In 1993, there were 12 full-time physicians practising on the island, six in Little Current, four in Mindemoya, and two in Gore Bay. There are two small hospitals on the island, one in Little Current and one 30 minutes by road away in Mindemoya. Both have 24-hour emergency coverage. Because there was no cross-coverage between hospitals, physicians were working a one in four to one in six emergency on-call schedule. On average in Little Current, physicians could expect two emergency cases between midnight and 8AM. Before 1990, obstetric care was divided between the two hospitals. In 1990, Mindemoya physicians Dr Osmun practises family medicine in Mount Brydges, Ont, and is an Assistant Professor in the Department of Family Medicine at the University of Western Ontario in London, Ont. Dr Poenn, a clinical teacher participating in the University ofOttawa's Northern Ontario Family Medicine Program, is on active staff and Ms Buie is Obstetrical Coordinator, at the Manitoulin Health Centre in Little Current, Ont.
Dr Roy Jeffery attends the delivery of John Osmun at Manitoulin Health Centre
stopped doing deliveries, citing lack of cesarean delivery backup and blood bank facilities. There were, and continue to be, about 100 deliveries each year on the island. Before Mindemoya physicians withdrew, physicians in Little Current delivered their own patients and participated in the on-call rota. After 1990, the increase in deliveries at the Little Current Hospital presented a challenge that called for changes in the provision of obstetric services on the island. To complicate matters, Little Current Hospital had lost its cesarean section capability with the semiretirement of its general practice surgeon. Many small hospitals in northern Ontario closed their obstetric units, leaving Sudbury as the closest referral centre for island patients. Sudbury is 1.5 hours by winding highway from Little Current and 3.5 hours from the farthest point on the island. This isolation made it necessary to maintain a feasible service that would provide care for the community.
1116 Canadian Family Physician . Le Medecin defamille canadien + VOL43: JUNE * JUIN 1997
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Program objective Manitoulin Island needed a safe, accessible source of obstetric care. The medical and nursing community had to assess the feasibility and safety of continuing obstetric care in Little Current. In the late 1980s and the 1990s, studies appeared demonstrating the safety of obstetrics in small rural units.7"'0 Low obstetric volume had been shown not to affect neonatal outcome adversely, but to result in a higher referral rate." The studies were consistent in showing that obstetrics seemed safe in GP-run rural units with careful screening. All studies had low numbers and therefore lacked statistical strength.
New program Hospital administrators were approached to establish a prenatal clinic in the hospital. A British-trained midwife was recruited to act as charge nurse for the obstetric ward and to organize and administer the clinic. Resident on the island for many years, she had close community contacts as well as many years of experience working in Mindemoya Hospital. Because her midwifery training had included training in obstetric clinics in the United Kingdom, she felt comfortable in obstetrics, in organizing clinics, and in providing patient education. The clinic operated 1 day weekly, and local physicians rotated through each week. Patients thus became familiar with all five physicians. Immediate postnatal care was provided by the delivering physician or the mother's regular family physician on staff. Postdischarge care was provided by the mother's regular physician. To improve physician working conditions, the physician on call for emergency provided obstetric coverage, thereby reducing total on-call hours. The physicians and the midwife met with interested nursing staff after hours to discuss obstetric care. The nursing staff were apprehensive about continuing care without cesarean section capability. Some, because the number of births had been declining, felt out of practice and uncomfortable with obstetrics. The initial meetings addressed safety. Attendance at these meetings was excellent, demonstrating motivation and acceptance of a new challenge. The physicians and midwife met to establish guidelines for obstetric care. Using the literature and drawing heavily on Enkin et al's A Guide to Effective Care in Pregnancy and Childbirth,'2 we reached a consensus for a standard of care. A checklist was created and placed at the front of each chart to aid in foliowing the guidelines and to enhance communication among caregivers.
Evaluation
Physicians involved think the reorganization has improved working conditions. They are sure of a night's sleep when they are not on call. Meetings of the obstetric working group encourage discussion, and caregivers feel more comfortable with obstetrics because the group provides support and guidance. Charts are audited by the midwife every 6 months.
Air ambulance landing on roof of Manitoulin Health Centre
The midwife was pleased with the reorganization because she realized that without change obstetric care would be threatened. She believes she is able to put her midwifery training to better use in the present situation, her role now extending beyond the traditional role of hospital-based nurse and including counseling and some assessment. She makes voluntary home visits to some of the patients and is effective in finding patients who have not attended the clinic and in encouraging them to attend. As a long-term resident of the island, the midwife functions effectively as an unofficial community liaison. She has not been able to expand her role to delivery, but is optimistic that she will obtain full midwifery licensure in the future. All mothers are asked to complete a questionnaire after delivery regarding their care. The response rate is disappointing, only 27% overall. When the clinic was first started, it had only a 48% approval rating. In the first 6 months of 1995, the approval rating improved to 75%. Change meets resistance; time, perhaps, has created a gradual acceptance of new ways. As well, as staff became more experienced, the clinic ran more efficiently, and this could have
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physicians and nurses in Little Current have organized a prenatal clinic in the hope of providing safe, uniform obstetric care to the mothers of Manitoulin Island. An obstetric working group, consisting of all physicians and the midwife, meet regularly to evaluate guidelines, formulate policies, and review patient outcomes. This forum provides ongoing continuing education to those involved and also serves to increase physicians' confidence in the quality of their obstetric care. Participation in an obstetric on-call rota tied to the emergency on-call schedule has improved physician satisfaction. Initial resistance to the prenatal clinic and shared care concept seems to be disappearing over time as the clinic becomes the "norm" and no longer a "new" mode of obstetric care. A weakness in our evaluation has been the disappointing number of patient questionnaires returned. Our situation is similar to obstetric practice by midwives, except that our working group is larger, six rather than four. In discussion with midwives, it is apparent that they spend more time with patients explaining the rationale and advantages of shared care. Patients need to be informed so they are not alienated by the process. A similar situation of providing shared family practice obstetric care in Calgary has recently been described.16 In retrospect, including a community representative to the obstetric working group during the reorganization probably gave an important perspective to the group and might have been a valuable liaison to the patients in their communities. Public meetings before the reorganization, especially in Mindemoya where local obstetric care was lost, might have eased the transition.
Table 1. Outcome of labour and deliveries OUTCOME
Transfers
NO. OF INTERVENTIONS N = 233 (%)
20 (8.6)
.............................................................................................................
Vaginal deliveries
211 (90.6)
.............................................................................................................
Breech deliveries
2 (0.9)
.............................................................................................................
Vacuum extractions
27 (11.6)
.............................................................................................................
Episiotomies Forceps Tears * First degree * Second degree * Third degree
36 (15.5) 1 (0.4)
56 (24.0) 31 (13.3) 7 (3.0)
.............................................................................................................
Postpartum hemorrhage Retained placenta
28 (12.0) 4 (1.7)
improved satisfaction ratings. Hospital care always receives high satisfaction ratings (93% to 100%), probably reflecting the community focus of small rural hospitals. All obstetric cases admitted to the Manitoulin Health Centre at Little Current in 1993 and 1994 were reviewed. Table 1 shows rates of interventions and complications. Three types of interventions were compared with available data from other Canadian rural sites and are tabulated in Table2101315 Our intervention rates are comparable to those reported in other studies.
Discussion Being available daily for deliveries can be taxing, especially when physicians are subject to the numerous other demands of rural practice. The
Conclusion Family practice obstetrics is threatened by medicolegal, educational, and lifestyle pressures.
Table 2. Intervention rates (%) from other studies MANITOULIN HEALTH CENTRE
QUEEN CHARLOTTE ISLANDS
GENERAL HOSPITAL's
LEMELIN'3
INTERVENTION
(N = 233)
(N = 192)
Episiotomy
15.5
Forceps, vacuum extraction
12.0
SPOONER
ROURKE'4
(N = 249)
AND GORMAN"0 (N = 362)
19.0
42.0
45.0
NA
2.0
9.0
16.0
20.0
(N = 237)
................................................................................................................................................................................................................................
Transfer
8.6
15.0
NA - not applicable. 1118 Canadian Family Physician . Le Medecin defamille canadien * VOL 43: JUNE * JUIN 1997
11.0
10.6
NA
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Nick Osmun enjoying a hildng trail on Manitoulin Island
Shared care is one good way to avoid physician exhaustion, to improve uniformity of care, and to keep physicians practising obstetrics. It is essential that patient education include discussion of the rationale of shared care so patients are not alienated by the process. When establishing new programs, it is important that all health care workers * be informed and involved in the changes.
Correspondence to: Dr WE. Osmun, Southwest Middlesex Health Centre, PO Box 219, Mount Brydges, ON NOL IWO
4. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA Access to obstetric care in rural areas: effect on birth outcomes. Am JPublic Health 1990;80:814-8. 5. Allen DI, Kamradt JM. Relationship of infant mortality to the availability of obstetrical care in Indiana.JFam Pract 1991;33:609-13. 6. Robertson JA, Card KD. Geology and scenety north shore of Lake Huron Region. Geological Guide Book 4. Toronto: Ontario Geological Survey; 1972. 7. Black DP, Fyfe IM. The safety of obstetric services in small communities in northern Ontario. Can Med Assoc J 1984; 130:571-6. 8. Rosenblatt RA, Reinken J, Shoemack P. Is obstetrics safe in small hospitals? Evidence from New Zealand's Regionalised Perinatal System. Lancet 1985;2:429-32. 9. Hogg W, Lemelin J. The case for small rural hospital obstetrics. Can Fam Physician 1986;32:2135-9. 10. Spooner GR, Gorman JA. A review of a rural Saskatchewan obstetric service, 1980-1985. Can Fam Physician 1988; 34:1881-4. 11. Tilyard MW, Wllliams S, Seddon RJ, Oakley ME, Murdoch CJ. Is outcome for general practitioner obstetricians influenced by workload and locality? NZ MedJ 1988; 101:207-9. 12. Enkin M, Keirse MJNC, Chalmers I. A guide to effective care in pregnancy and childbirth. Oxford, Engl: Oxford University Press; 1991. 13. Lemelin J. Referral pattern and rate of intervention in a small rural obstetrical practice. Can Fam Physician 1986; 32:2141-6. 14. Rourke JTB. Caesarean section, epidural, and forceps intervention rates for low-risk obstetric deliveries. Can Fam Physician 1989;35:2025-8, 2161. 15. Grzybowski SCW, Cadesky AS, Hogg WE. Rural obstetrics: a 5-year prospective study of the outcomes of all pregnancies in a remote northern community. Can Med Assoc J 1991; 144:987-94. 16. Lane CA, Malm SM. Innovative low-risk maternity clinic. Family physicians provide care in Calgary. Can Fam Physician 1997;43:64-9.
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