On behalf of the Society of Rural Physicians of Canada, we believe that the study by Lisonkova and colleagues1 does a disservice to rural maternity providers, and fails to address the factors that most influence maternal morbidity and perinatal outcomes.
The authors allude to the fact that closure of rural maternity units may have played a role in the outcomes in their study; however, they downplay this fact and choose to focus on the providers, suggesting that, “the emphasis should remain on monitoring for potentially life-threatening maternal and perinatal complications....” In our experience, rural maternity care practitioners would not neglect to notice when preeclampsia progressed to eclampsia, for example. With reduced access to maternity care, women in rural Canada will present later, attend less frequent appointments or even choose to avoid transfer for delivery, which results in an increased risk of complications. Further, general health care teams are less prepared than rural teams when women make these choices.
We cannot ignore the need to provide local access to care. Pregnant women in rural areas tend to be younger, have higher rates of smoking or substance use, and have pre-existing hypertension. When a pregnancy is labelled high risk, will a woman choose to leave her family, sometimes for weeks before delivery, and travel hundreds (or thousands) of kilometres to receive care? Will she want to deliver where the culture and language may be different, at substantial personal financial cost, and where her support people may not be present?
In areas with primary maternity care (no cesarean delivery), low-volume maternity units or maternity care with family physicians with enhanced surgical skills for cesarean delivery, rural women have outcomes equal to those of their urban counterparts. As rural and urban maternity care providers, we should be advocating strongly for the strengthening of rural maternity services to improve maternal and neonatal outcomes. It is what rural women want and deserve.