Evans, Rebecca Jane (2009) Health policy and rural maternity care: four case studies in north Queensland. PhD thesis, James Cook University.

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Abstract

Equity, access, safety and quality are prominent themes in Australian health policy. Yet, in one area of health care, maternity services, rural facilities have continued to close. During 1995-2005, over 130 rural maternity units closed across Australia and 36 out of 84 units closed throughout Queensland. These closures raise serious concerns about equity of access to, and quality of, maternity care for rural residents. Few studies examine the relationship between policy discourse and citizens’ lived experiences of policy outcomes. However, it is important that policy-makers obtain such qualitative information to discern the appropriateness of present strategies and to inform future policy-making. This project was guided by two research questions, namely, to identify prominent policy influences on rural maternity care and to understand the lived experiences of residents who provide and/or access this care in rural north Queensland. A methodology comprising a policy review followed by four case studies was used to explore the relationship between health policy discourse and the lived experiences of rural residents in seeking or providing maternity care.

Thematic analysis of relevant policies was undertaken to better understand the present policy environment and resulted in the identification of a number of key themes. Firstly, there were overarching themes of equity of access to care found in large-scale policies. Secondly, very little policy support specifically for rural maternity services could be found; this insufficiency was also emphasised during interviews with health professionals. Thirdly, policy discourse revealed an inclination to centralise health services. This, mostly implicit, policy direction was reinforced by the reality of service migration away from rural towns and towards more urbanised centres. Fourth, there was a notable emphasis on avoiding clinical risks which subsequently influenced the practice of rural maternity care professionals. Fifth, achieving cost-efficiencies was a concern in many, particularly state-level, policies which is characteristic of corporate rationalists.

Case studies of four rural north Queensland towns were completed and illustrated the lived experiences of residents who seek and provide maternity care. The four case study sites experienced a variety of outcomes: one town had recently seen their birthing service close; another unit had just established an innovative midwifery-led model of care; another provided maternity care in the traditional medical model and had retained a robust proceduralist roster; and yet another officially had a service, though it was quite inconsistent. Despite the variety of outcomes, all maternity units experienced a common pressure to constrain services and all had faced some service downgrading. A number of recurrent themes emerged through the inductive analysis of data and were sorted into four groups.

Firstly, there were themes closely related to community. It was clear that rural communities still valued local maternity services, especially birthing. For most individuals, local services offered a more convenient and acceptable option for accessing maternity care. At a community level, viable local maternity services were perceived as important for the sustainability of rural towns. The level of true community engagement with health services or policy was found to be negligible, although locally initiated public action was instrumental in maintaining services at two of the towns. The majority of interviewees, especially health professionals, saw benefits in engaging the local community in health service decision-making, but they also held common reservations about the success of such initiatives in their own towns.

Secondly, workforce insufficiencies remained the biggest threat to the sustainability of rural maternity units. Despite the considerable policy attention that has been paid to rectifying the maldistribution of medical practitioners, recruitment and retention difficulties still caused major problems for all the maternity units in this study. Ageing and short supply of rural midwives were equally pressing. The progressive downgrading of services led to (a) a loss of local skills as health professionals left to practice in other towns, or else remained and ultimately became de-skilled; and (b) a collective demoralisation among hospital staff with progressively less scope to provide holistic health services of a high quality with continuity of carers.

Thirdly, the quality of care (not necessarily clinical quality) experienced by rural residents was profoundly affected by the downgrading of rural maternity services in a number of ways. Most obviously, the loss of services caused less equitable geographic access to care. This led to the introduction of more carers and facilities, thus causing care to become increasingly fragmented. In addition, the financial costs of accessing care increased significantly for rural residents and included costs of regular travel, lost work and relocation to the regional centre weeks prior to delivery.

Fourth, there were issues of safety and risk. Many health professionals reported the pressure they felt in reconciling higher patient expectations of health care with the nature of adverse events in obstetrics. This pressure was exacerbated by a policy environment that was perceived as highly risk-averse. For rural residents, the removal of local services appeared to encourage them to take more risks in accessing maternity care. Further safety concerns were voiced by health professionals in relation to the cessation of rural birthing services. The subsequent loss of important clinical skills leading to reduced capacity to manage local obstetric emergencies also threatens the sustainability of a range of other local health services.

Overall, it was found that government policies and the general policy environment did not support the sustainability of rural maternity services. Instead, rural maternity units were vulnerable to pressures of service centralisation, achieving cost-efficiencies and risk-aversion. Thus, while rural maternity units are not supported and continue to close, disparities in the geographic location of birthing units grow, ultimately having the effect of transferring to rural families the costs and risks that were once borne by the government. A number of recommendations for future policy-making emerge from the findings of this study including the need for specific policies to support rural maternity services; developing policy initiatives to bolster the workforce, infrastructure and models of rural maternity care; and the implementation of policies which better compensate rural residents for decreased geographic access to services.

Item ID:	11948
Item Type:	Thesis (PhD)
Keywords:	Queensland health services, birthing centres, rural maternity services, public policies, health service delivery, obstetric skills, centralization of services, midwifery, risk management
Related URLs:	http://eprints.jcu.edu.au/7115 http://eprints.jcu.edu.au/7114
Copyright Information:	Copyright © 2009 Rebecca Jane Evans
Additional Information:	Publications arising from this thesis are available from the Related URLs field. The publications are: Hays, R.B., Evans, R.J., and Veitch, C. (2005) The quality of procedural rural medical practice. Rural and Remote Health, 5 (474). pp. 1-11. ISSN 1445-6354. Hays, R. B., Veitch, C., and Evans, R. (2005) The determinants of quality in procedural rural medical care. Rural and Remote Health, 5 (473). pp. 1-10. ISSN 1445-6354
Date Deposited:	14 Oct 2010 06:02
FoR Codes:	11 MEDICAL AND HEALTH SCIENCES > 1114 Paediatrics and Reproductive Medicine > 111402 Obstetrics and Gynaecology @ 50% 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111717 Primary Health Care @ 50%
SEO Codes:	92 HEALTH > 9202 Health and Support Services > 920208 Health Inequalities @ 50% 92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920506 Rural Health @ 50%
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