A fix for disappearing surgery and maternity care in rural Canada

An important and unprecedented collaboration between Canadian surgeons, obstetricians/gynaecologists, and family doctors aims to address the wave of closures of maternity services and small-volume surgical programs in rural parts of Canada. Together, the Canadian Association of General Surgeons, the Society of Obstetricians and Gynaecologists of Canada, the College of Family Physicians of Canada, and the Society of Rural Physicians of Canada developed a Joint position paper on rural surgery and operative delivery, which was published in the Canadian Journal of Rural Medicine. The paper is part of an integrated, multidisciplinary, evidence-based plan to ensure the availability of well-trained practitioner teams to sustain safe, effective, and high-quality rural surgical and obstetric services.

“In Canada there has been a significant attrition of rural maternity services over the past 15 years. We know that rural maternity services are more sustainable when they are supported by surgical services (caesarean section). This requires attention on other surgical services to underscore them,” explains Vancouver Coastal Health Research Institute scientist and paper co-author Dr. Jude Kornelsen. “That our organizations have all come together to admit this is a problem and come up with a theoretical solution that we’re all on board with is phenomenal. This has been many decades coming.” 

In their paper, the authors propose that a networked system of specialist-generalist surgical care, in which there would be formal interprofessional service networks between small surgical services and regional referral and tertiary services, would be the most effective way to meet surgical and maternity care needs within Canada’s rural communities. 

Previous studies have shown that when women from rural areas have to travel to access labour and delivery health services, they and their newborns experience more adverse outcomes and increased interventions. And when other health care services require a patient to travel far from home, patients bear the social costs of separation from family and community, including but not limited to the health and well-being of family members left behind, and financial implications for the family.

The authors’ proposed network model has small operating rooms recognized as extensions of core referral hospital programs. Similar hub-and-spoke models have been successfully implemented in other countries such as Australia. 

Also central to the researchers’ proposal is extra training for general practitioners (GPs) who would like to gain enhanced surgical skills for procedures such as appendectomies, endoscopies, hernia repair, etc. 

“Sustaining surgical services and affecting the best population outcomes is going to depend on a strong work force of such GPs,” says Dr. Kornelsen, who is also an associate professor in the Department of Family Practice and co-director of the Centre for Rural Health Research in the Faculty of Medicine at the University of British Columbia. “We have to start thinking about training; we don’t have that right now.”

“Primary maternity care is more sustainable when there exists surgical backup for Caesarean sections (C-sections). And we know that surgical backup can’t just be providing C-sections – we need to have a whole operating-room slate with folks able to do small procedures in these rural communities,” adds Dr. Kornelsen. 

“If we organize these networks, we have the incredible potential of having a lot of the surgical procedures that are currently done in the big operating rooms done in the smaller ones and that would definitely have an impact system-wide.”

While there may be some trepidation around extending GPs’ responsibilities into the surgical arena, studies have shown that GPs with enhanced surgical skills have very good outcomes for procedures deemed appropriate and that safety is not an issue.

“Also, to have the Canadian Association of General Surgeons and the Society of Obstetricians and Gynaecologists on board, saying, ‘Yes, we need to move forward on this to make sure we have good population health outcomes,’ is fantastic,” adds Dr. Kornelsen.

Dr. Kornelsen and her collaborators are currently discussing next steps such as moving to a proof-of-concept phase where they attempt setting up a formalized network and solidifying an implementation plan.

“I think this is an absolute step in the right direction,” says Dr. Kornelsen. “For all patients in B.C. and Canada, supporting maternity care and small surgical services will lead to better patient outcomes.”