In rural Canada and Australia, as well as in most other industrialized nations, we are currently witnessing the constriction of maternity services, characterized by the movement of services away from rural communities and into more populous settings. This has been prompted by a variety of factors including the general move towards healthcare centralization in the age of subspecialists1,2, growing risk aversion in the absence of such specialists3-5, challenges recruiting and retaining providers to work in low resource environments6-9 and, ostensibly, costs10-12.
An argument used to support the centralization of services has been one of safety. This is underscored by the assumption that high procedural volume is assumed to be related to safer birth13-15. It is our view that this argument has been settled with substantial evidence pointing to the safety of small (low volume) obstetric units16-28.
We would like to build from this evidence base to consider a relatively unexplored assumption underscoring debates on centralized versus decentralized rural services: that centralized services are more cost-effective.
The assumed efficiencies of scale embedded in the centralization model are believed to lead to cost-effectiveness. However, we have been unable to find any evidence to support this, particularly when we take a societal perspective29. For residents of rural communities, this assumption has meant the loss of local access to many rural health services, and the attendant decrease in healthcare-related jobs that can spiral into diminished social capital and loss of future development for a community30,31. Maternity care for rural populations is notably impacted, with psychosocial32,33 and physiological consequences17,34-36 following local service closures13-16.
We suggest that health planners must consider taking a societal perspective to measure comprehensive costs when planning health services. This imperative is not without its challenges.
From an evidence-based planning perspective, decisions must be made to determine what constitutes reasonable access to maternity care services for rural populations and what evidence we have with respect to comprehensive costs. We suggest that health planners are still determining the answer to the former and identifying significant evidence gaps in the latter. The goal of this article is to signal an overt step towards a conceptual framework and methodology for inclusive costing of rural maternity and other health services.
Triple aim framework: an organizing structure
A current driver in healthcare planning is adherence to the Institute of Healthcare Improvement's Triple Aim, a framework designed to optimize health system performance37. At its most basic, optimization involves simultaneous attention to improvement in three key determinants: population health, the experience of care, and per capita costs. Although theoretically sound, several authors have acknowledged the gap between the framework and its successful implementation38,39, leading to a suggested set of preconditions necessary to accomplish its realization39. The first precondition is a clear definition of the population of concern as a baseline for understanding its 'experience of care, its health status, and the per capita costs of caring for it'40. Further, a clear understanding of external policy constraints is fundamental to successful implementation, along with the existence of a coordinating service to maintain focus on all three dimensions equitably.
To these suggestions, we would add the need for an additional precondition: taking a societal perspective in measuring costs when planning health services. It is crucial for us to include outcomes such as psychosocial stress in our costing equations. These, alongside potential physiological consequences of lack of access to care, are an essential baseline for understanding true cost17,33-35. Neglecting these realities will lead to an inadequate appraisal of influencing factors and, more importantly, decision consequences.
Cost shifting and indirect costs as system influencers
Even in standard practice, consideration of the immediately tangible, quantifiable, and manifest costs of maintaining a rural maternity service raises significant challenges to comprehensiveness. The challenges are rooted in the propensity to count costs that are easily measured (capital, operating, and provider) without regard for cost shifting (reallocating costs to different parts of the system), cost downloading (passing costs on to women and families), or additional external costs.
Cost shifting includes the transfer of expenses for things that are no longer in the domain of the body responsible for running local services but are still incurred by the system. In the example of the closure of a small primary maternity service, this would include facilities and provider costs in a different location, perhaps outside of the administrative boundaries of the local health authority. Although immediate costs will not be borne by the local administration, they will be incurred in other parts of the system (assuming the birth takes place somewhere with the support of some other professional). The displaced births will likely occur 'upstream' at a hospital with a higher level of service and more frequent interventions, ultimately at a higher overall cost. From a societal costing perspective, birthing women and families need to spend more money on travel, food, and/or childcare while they are birthing in a hospital further from home41. In this scenario, costs removed from the health service system do not simply disappear, but are downloaded onto women and families who have to travel for care.
There will be some indirect cost consequences with the closure of a local service. In the instance of rural maternity care, maternal stress precipitated by lack of local services resulting in complications such as preterm delivery and low birthweight infants is a reality that can lead to increased days in neonatal intensive care and the attendant costs of this admission17. These additional costs were noted in a provincial study in British Columbia reviewing outcomes based on distance to care. The study also found that the smaller cohort of women who live in remote communities that are referred to a larger community hospital have a three times higher perinatal mortality rate associated with travelling more than 4 hours17.
Further indirect costs need to be considered as potentially contributing to the cost shift. These may include events potentially related to travelling for maternity care, such as emergency response costs of roadside deliveries or, worse, response to traffic accidents due to road conditions and/or driving in an emergency situation.
In a comprehensive framework, consideration of costs requires attention to what is sacrificed or lost to achieve the desired goal. This should include psychosocial and cultural costs to women and their families, which have been rigorously documented in both Canada and Australia. They include increased stress and anxiety throughout pregnancy, labor, and delivery32; the absence of kinship and community support at the time of birth42; and the potential disruption of family relationships42. Cultural consequences are articulated most vividly by Aboriginal communities, and have been described as the loss of the closure of the cycle of life and death (when there is only death and never birth in the community), and the loss of maintaining the lineage of historical connection to the land43.
Towards an inclusive methodology
Low representation in the political process is an inherent disadvantage for rural communities: available voters often do not provide enough weight to sway political decision-making, let alone elections. If we can accept, as the adage suggests, 'not everything that can be counted counts, and not everything that counts can be counted'44, we are compelled to find alternative ways of acknowledging the indirect, hidden, latent costs incurred by these communities. The methodology to do this will be rooted in the rich descriptions of those suffering such losses and must be reconciled alongside the 'hard' and 'soft' costs incurred. Further, it is the narrative itself that will alert us to categories of meaningful consideration that might otherwise be overlooked. Description, however, is not measurement, and the difficulty of creating a metric to capture the psychosocial and cultural 'loss' of local service closure is evident.
Pursuit of a framework
The pursuit of a framework for the comprehensive costing for rural maternal health services must start by comparing costs of services weighed against costs of not having services. Table 1 represents a starting place for delineation. Weighing the costs of services against the costs of not having services should be done across three defined rural maternity care service levels: for communities without maternity care, for communities with primary care but no access to cesarean section, and for communities with surgical backup supports by general practitioners with enhanced surgical skills. Within these groups, there are a variety of manifest (immediately identifiable) costs when providing maternity care services in the community, and latent (hidden) costs when referring birthing women outside the community. These two types of cost are applicable to the three defined rural maternity care service levels.
Although it may be tempting to attribute dollar amounts to the latent costs so they can be more easily reconciled with the concrete costs, this would be an error of reduction open to either under- or overrepresenting the 'costs of separation'. Instead, they should be recognized as a source of key context in interpreting concrete costs. These costs must be gleaned through structured interviews with mothers, healthcare providers, hospital administrators, and community members.
Table 1: Framework for comprehensive costing of rural maternity care services
The latent cost consequences of rural maternity care closures are difficult to not only measure, but also capture as a category of consideration within the pragmatic costing framework we currently apply to health care. We have articulated the clear evidence for loss and cost due to the psychosocial32,33 and physiological consequences17,34-36 for childbearing women. We anticipate that the process of thinking through the potentially wide-ranging effects of local services needed - or the loss of those services - in a comprehensive analysis will lead to a more accurate understanding of the cost-benefit ratio. Until we have developed a mechanism to acknowledge and account for costs in an inclusive way, however, the assumption that centralized services are more efficient must be viewed with significant suspicion.
The authors acknowledge the editorial assistance of Max McAlpine, Centre for Rural Health Research.
1. Iglesias A, Iglesias S, Arnold D. Birth in Bella Bella: emergence and demise of a rural family medicine birthing service. Canadian Family Physician 2010; 56(6): e233-e240.
2. Pong RW, Pitblado JR. Geographic distribution of physicians in Canada: beyond how many and where. Canadian Institute of Health Information 2005; 1-63.
3. Hoang H, Le Q, Kilpatrick S. Small rural maternity units without caesarean delivery capabilities: is it safe and sustainable in the eyes of health professionals in Tasmania? Rural and Remote Health 2012; 12(1941): 1-11.
5. Moster D, Lie RT, Markestad T. Relation between size of delivery unit and neonatal death in low risk deliveries: population based study. Archives of Disease in Childhood - Fetal and Neonatal Edition 1999; 80(3): F221-F225. https://doi.org/10.1136/fn.80.3.F221
6. Benoit C, Carrol D, Millar A. But is it good for non-urban women's health? Regionalizing maternity care services in British Columbia. Canadian Review of Sociology and Anthropology 2002; 29(4): 371-395. https://doi.org/10.1111/j.1755-618x.2002.tb00626.x
7. Brooks R, Walsh M, Mardon R, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Academic Medicine 2002; 77(8): 790-798. https://doi.org/10.1097/00001888-200208000-00008
8. Rogers J. Sustainability and collaboration in maternity care in Canada: dreams and obstacles. Canadian Journal of Rural Medicine 2003; 8(3): 193-198.
9. Society of Rural Physicians of Canada. Nurse practitioners and rural medicine: voices from the field. Proceedings from the Annual Policy Conference. St John's, Newfoundland: Society of Rural Physicians of Canada, 1988.
10. Iglesias S, Grzybowski S, Klein MC, Gagne GP, Lalonde A. Rural obstetrics: joint position paper on rural maternity care. Joint working group of the Society of Rural Physicians of Canada, the Maternity Care Committee of the College of Family Physicians of Canada, and the Society of Obstetricians and Gynaecologists of Canada. Canadian Family Physician 1998; 44: 831-843.
11. Kornelsen J, Grzybowski S. Safety and community: the maternity care needs of rural parturient women. Journal of Obstetrics and Gynaecology Canada 2005; 27(6): 554-561. https://doi.org/10.1016/S1701-2163(16)30712-5
13. Heller G, Richardson DK, Schnell R, Misselwitz B, Kunzel W, Schmidt S. Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990-1999. International Journal of Epidemiology 2010; 304(9): 992-1000.
14. Moster D, Lie RT, Markestad T. Neonatal mortality rates in communities with small maternity units compared with those having larger maternity units. BJOG 2001; 108(9): 904-909. https://doi.org/10.1111/j.1471-0528.2001.00207.x
15. Merlo J, Gerdtham U, Eckerlund I, Hakansson S, Otterblad-Olausson P, Pakkanen M, et al. Hospital level of care and neonatal mortality in low- and high-risk deliveries: reassessing the question in Sweden by multilevel reassessing analysis. Medical Care 2005; 43(11): 1092-1100. https://doi.org/10.1097/01.mlr.0000182484.14608.b9
16. Rosenblatt RA, Reinken J, Shoemack P. Is obstetrics safe in small hospitals? Evidence from New Zealand's regionalized perinatal system. Lancet 1985; 2(8453): 429-432. https://doi.org/10.1016/S0140-6736(85)92747-3
17. Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Services Research 2011; 11(1): 147. https://doi.org/10.1186/1472-6963-11-147
18. Urbach DR, Croxford R, MacCallum NL, Stukel TA. How are volume-outcome associations related to models of health care funding and delivery? A comparison of the United States and Canada. World Journal of Surgery 2005; 29(10): 1230-1233. https://doi.org/10.1007/s00268-005-7994-7
20. Grytten J, Monkerud L, Skau I, Sorensen R. Regionalization and local hospital closure in Norwegian maternity care - the effect on neonatal and infant mortality. Health Services Research 2014; 49(4): 1184-1204. https://doi.org/10.1111/1475-6773.12153
21. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA 2010; 304(9): 992-1000. https://doi.org/10.1001/jama.2010.1226
22. Tracy SK, Sullivan E, Dahlen H, Black D, Wang YA, Tracy MB. Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women. BJOG 2006; 113(1): 86-96. https://doi.org/10.1111/j.1471-0528.2005.00794.x
23. Grzybowski S, Stoll K, Kornelsen J. The outcomes of perinatal surgical services in rural British Columbia: a population-based study. Canadian Journal of Rural Medicine 2013; 18(4): 123-129.
24. Grzybowski S, Fahey J, Lai B, Zhang S, Aelicks N, Leung BM, et al. The safety of Canadian rural maternity services: a multi-jurisdictional cohort analysis. BMC Health Services Research 2015; 20(4): 129-138. https://doi.org/10.1186/s12913-015-1034-6
25. Ravelli CJ, Jager KJ, de Groot MH, Erwich JJ, Rijninks-van Driel GC, Tromp M, et al. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands. BJOG 2011; 118(4): 457-465. https://doi.org/10.1111/j.1471-0528.2010.02816.x
26. Combier E, Charreire H, Le Vaillant M, Michaut F, Ferdynus C, Amat-Roze JM, et al. Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy. Health Place 2013; 24: 225-233. https://doi.org/10.1016/j.healthplace.2013.09.006
27. Paranjothy S, Watkins W, Rolfe K, Adappa R, Gong Y, Dunstan F, et al. Perinatal outcomes and travel time to maternity services: analysis of birth outcome data in Wales from 1995 to 2009. Archives of Disease in Childhood - Fetal Neonatal Edition 2013; 98(Suppl 1): A94. https://doi.org/10.1136/archdischild-2013-303966.323
28. Kornelsen J, McCartney K, Newton L. The safety of rural maternity services without local access to cesarean section. Vancouver, BC: Applied Research Unit realist review, 2015.
29. Drummond MF, Sculpher MJ, Torrance GW, O'Brian BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 3rd Edn. New York: Oxford University Press, 2005.
30. Miewald C, Klein MC, Ulrich C, Butcher D, Eftekhary S, Rosinski J, et al. 'You don't know what you've got till it's gone': The role of maternity care in community sustainability. Canadian Journal of Rural Medicine 2011; 16(1): 7-12.
31. Doeksen GA, St Clair CF, Eilrich FC. The economic impact of a critical access hospital on a rural community. Stillwater, Oklahoma: National Center for Rural Health Works, 2012.
32. Kornelsen J, Stoll K, Grzybowski S. Stress and anxiety associated with lack of access to maternity services for rural parturient women. Australian Journal of Rural Health 2011; 19(1): 9-14. https://doi.org/10.1111/j.1440-1584.2010.01170.x
33. Hoang H, Le Q, Ogden K. Women's maternity care needs and related service models in rural areas: a comprehensive systematic review of qualitative evidence. Women Birth 2014; 27(4): 233-241. https://doi.org/10.1016/j.wombi.2014.06.005
34. Steenkamp M, Rumbold A, Barclay L, Kildea S. A population-based investigation into inequalities amongst Indigenous mothers and newborns by place of residence in the Northern Territory, Australia. ?BMC Pregnancy Childbirth 2012; 12: 44. https://doi.org/10.1186/1471-2393-12-44
35. Pilkington H, Blondel B, Drewniak N, Zeitlin J. Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France. European Journal of Public Health 2014; 24(6): 905-910. https://doi.org/10.1093/eurpub/ckt207
36. Blondel B, Drewniak N, Pilkington H, Zeitlin J. Out-of-hospital births and the supply of maternity units in France. Health Place 2011; 17(5): 1170-1173. https://doi.org/10.1016/j.healthplace.2011.06.002
37. Institute for Healthcare Improvement. The IHI Triple Aim. (Internet). Available: http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx (Accessed 15 May 2015).
39. Prior M, McManus M, White P, Davidson L. Measuring the 'triple aim' in transition care: a systematic review. American Academy of Pediatrics 2014; e1648-e1661.
41. Gao Y, Barclay L, Kildea S, Hao M, Belton S. Barriers to increasing hospital birth rates in rural Shanxi Province, China. Reproductive Health Matters 2010; 18(36): 35-45. https://doi.org/10.1016/S0968-8080(10)36523-2
42. Kornelsen J, Grzybowski S. The costs of separation: the birth experiences of women in isolated and remote communities in British Columbia. Canadian Woman Studies 2004; 24(1): 75-80.
43. Kornelsen J, Kotaska A, Waterfall P, Willie L, Wilson D. The geography of belonging: the experience of birthing at home for First Nations women. Health and Place 2010; 16(4): 638-645. https://doi.org/10.1016/j.healthplace.2010.02.001
44. Cameron WB. Informal sociology: a casual introduction to sociological thinking. New York: Random House, 1963.