Background

Anesthesia services are a vital part of the maternal newborn safety net within the Canadian health care system. Anesthesia services include: pre-labor and pre-Cesarean medical consultations and use of labor epidurals as part of obstetric, medical, and anesthetic risk management during childbirth, high quality labor epidural pain relief, primary maternal medical and anesthesia care during operative deliveries, and management of peripartum pain. Importantly, anesthesiologists and family practice (FP/GP) anesthetists provide frontline emergency medical care during crises that require maternal (and in some institutions neonatal) resuscitation and acute maternal medical stabilization and intensive care during life-threatening emergencies (e.g., hemorrhage, pre-eclampsia/eclampsia) that occur in the peripartum period.

Unlike other professions contributing to maternal newborn care, health services research related to obstetrical anesthesia care in Canada is virtually non-existent. The important contributions made by anesthesiologists and FP/GP anesthetists to maternal newborn safety and care within the system are poorly reported, are not interpreted, and are largely unrecognized in national and provincial perinatal reports. Obstetrical anesthesia care is commonly reduced to epidural frequencies and Cesarean delivery rates. Other important aspects of the provision of obstetrical anesthesia services that are not reported include common adverse outcomes and the impact of the limitation of anesthesia services on maternal care, maternal safety, and birth outcomes within the system, particularly in small town and rural hospitals.

Despite these limitations, the data reported bears witness to the overall large and important role played by obstetrical anesthesia providers during labor and delivery. In the most recent Canadian Perinatal Report, more than one-in-three women in the nation received obstetrical anesthesia care as an essential service in 2004 and 2005 (Cesarean delivery rate 25.6%, operative vaginal delivery rate 14.8%, forceps 4.6%).1 The most recent Ontario Provincial Report, which provides additional data regarding epidural use, suggests an even greater role.2 In 2005 and 2006, more than 60% of parturients in the province received anesthesia care during labor and delivery (labor epidurals 59%, Cesarean delivery 28%, forceps and vacuum 13%). Compared with the levels of involvement by primary providers of obstetric care during childbirth in Ontario, the frequency of obstetrical anesthesia provider involvement ranked second only to obstetricians (obstetricians 86%, anesthesiologists/FP anesthetists more than 60%, FP obstetricians 9%, and midwives 4%).

To date, several national and provincial reports have focused on Canada’s capacity to provide primary maternity care due to a shortage of providers.3–5 The limited information available also suggests that significant issues exist regarding provision of obstetrical anesthesia care, particularly in small town and rural communities. Authors of Ontario provincial perinatal reports have noted an association between a shortage of the availability of anesthesia services and closure of maternity services in small town and rural hospitals6 and an association between a shortage of maternal access to epidural pain relief and urbanization of low-risk maternity care.2,7 A 2005 Ontario hospital survey identified anesthesia providers as the group most commonly limiting hospital capacity to provide Cesarean deliveries. Of 102 hospitals surveyed, 28% reported intermittent Cesarean delivery capacity and 9% reported no local capacity for Cesarean delivery.8 Despite these issues and the recognized shortage of anesthesia providers in these communities,9,10 little research has been conducted to explore the issues and barriers they encounter related to provision of services or systems of support.

This paper presents findings from a secondary analysis of data obtained from physician leaders in a larger provincial study that was also conducted by the authors.11 The primary study explored a variety of areas with physicians across Ontario regarding the provision of obstetrical anesthesia care, including local obstetrical anesthesia practices, issues and barriers to provision of services, and potential solutions. The current study focused specifically on the issues and barriers physicians encountered in community hospitals with fewer than 2,000 deliveries per annum, and it also explored potential solutions. We chose to focus on this group of providers for two reasons: (1) Leaders within the Child Health Network (Greater Toronto Area) involved in maternal newborn care suggested delivery volumes of 2,000 or more as the threshold required to provide efficient, high quality maternal care within maternity units;12 and (2) Findings from our larger provincial study suggested that physicians in these hospitals, particularly small rural hospitals, were in most urgent need of supports and solutions from the health care system to ensure continued provision of services.

Methods

Following Sunnybrook Health Sciences Centre Research Ethics Board approval, we performed a secondary analysis of the qualitative data collected in a larger Ontario study from 18 physician participants. The primary study involved 28 physician leaders representing the spectrum of obstetrical anesthesia care from large urban to rural remote Ontario hospitals. The study, which is reported elsewhere,11 employed a three-phase, sequential mixed-method research design using both a qualitative exploratory descriptive approach13 and a quantitative practice survey approach. Data were collected in the summer of 2005.

The current study specifically focused on and analyzed all of the data from the primary study that addressed the provision of obstetrical anesthesia services in community hospitals with fewer than 2,000 deliveries. The data explored were from four university-based obstetrical anesthesia leaders and 14 FP/GP anesthetist and anesthesiologist leaders representing community hospitals with fewer than 2,000 deliveries per annum. Community hospitals were sampled using a purposeful strategy of maximum variation based on delivery volumes, level of neonatal care, and geographic region in Ontario. Hospitals were located outside of major metropolitan areas and represented all five geographic regions of Ontario (Fig. 1). Physician leaders from these hospitals (Director of Obstetric Anesthesia, Department Head of Anesthesia, or anesthesia provider most responsible) participated in at least one-of-three focus groups exploring issues and barriers encountered regarding obstetrical anesthesia care in their hospitals and their potential solutions (Box 1). To further explore potential solutions, leaders from all major university-based obstetrical anesthesia teaching programs were invited to participate in a final physician focus group with community hospital key informants. Eighty-two percent (14/17) of the community anesthesia leaders who were invited participated in one or more focus group. Obstetrical anesthesia leaders from three of six university-based obstetrical anesthesia teaching programs participated. All participants had been in practice for at least 3 years.

Fig. 1
figure 1

Geographic map of 14 hospitals represented by anesthesia leaders from hospitals with fewer than 2,000 deliveries per annum

Full size image
Box 1 Focus group semi-structured interview guide
Full size table

Focus groups were held via teleconference and were moderated by the physician investigator and an assistant moderator. The focus groups included four or five participants, lasted 1.5 to 2.5 h, were audio-taped, and were transcribed verbatim. At the conclusion of each focus group, member-checking was used to verify the researchers’ initial interpretation of key issues.14 Researchers debriefed after each session and identified issues requiring further exploration in subsequent focus groups until saturation of responses. In the final focus group, findings from previous focus groups were initially described to provide a context for physicians from university-based maternity anesthesia teaching programs as well as to further cross-validate findings with key informants prior to exploring potential solutions.

Qualitative content analysis was used for the analysis.13 Transcripts were initially read to check for accuracy and to provide a comprehensive view of each physician’s discussion. A provisional list of codes was developed from the focus group interview schedule. The researchers (an obstetric anesthesiologist/researcher and a labor nurse/health services researcher) independently read transcripts and, with the assistance of the software, NVivo QSR 2.0,Footnote 1 they applied the devised codes to portions of the data. They then used pattern coding and memo linking observations to facilitate making inferences from the data. Codes representing similar ideas within and across focus groups were clustered into categories (themes and sub themes). The two reviewers compared emerging analyses and, through critical discussion, consensus was reached on the development of new codes and categories needed to represent the data. Data collected on the physician practice survey were entered into SPSS 12.0.Footnote 2 Descriptive statistics were used to present the demographic characteristics of the hospitals sampled and the participants representing them.

Results

The characteristics of the participants and the community hospitals they represented are shown in Table 1. Three themes, each comprised of two or three subthemes, emerged from the data. The themes were profusely interwoven and interactive; however, for the purposes of presentation, they are discussed separately in the paper.

Table 1 Characteristics of focus group participants from hospitals with <2,000 deliveries
Full size table

Obstetrical anesthesia in the “periphery”

The theme, Obstetrical Anesthesia in the Periphery, had three subthemes that described the greater context in which obstetrical anesthesia services are provided in community hospitals outside large metropolitan areas. The first sub theme was Rural Anesthesia is Not like Big City Anesthesia (Box 2A). Participants indicated that specialist anesthesiologists provide complex anesthesia care in large community hospitals while FP/GP anesthetists provide most of their anesthesia services in small and rural communities. Family practitioner anesthetists described themselves as medical services multi-taskers who provide a variety of family medicine (e.g., office, obstetric, emergency ward, and nursing home care) and anesthesia services for their communities. While multi-tasking is necessary to earn a living in their low-volume practice settings, 24-h on-call coverage of anesthesia and family medicine is onerous and complex.

Box 2 Obstetrical anesthesia in the “periphery”
Full size table

The second subtheme, The Heavy Toll of the Anesthesia Human Resources Shortage in the Periphery (Box 2B), reflected the impact of the anesthesia human resources shortage on providers and services. Staffing shortages were described among anesthesiologists in distant large community hospitals and FP/GP anesthetists in small town and rural hospitals. Both groups voiced concern over the future capacity of providing anesthesia services in their communities. The greatest shortages were described by FP/GP anesthetists, who noted that the deficiency worsens as communities decrease in size and increase in distance from large southern Ontario cities. Family practitioner anesthetists explained that FP/GP anesthesia shortages, once far removed from major urban centers, were now present in community hospitals in close proximity to cities and that small town and rural communities “compete” for scarce anesthesia resources. Designation of more desirable communities in close proximity to southern Ontario cities as underserviced left rural remote providers unable to compete for the scarce supply of anesthesia practitioners. Providers from desirable small town and rural communities indicated that the underserviced designation was the main reason that they were able to offer the level of anesthesia services currently provided. Family practitioner anesthetists voiced frustration over difficulties with recruitment and retention, inadequate numbers of FP/GP anesthetists being trained, and lack of incentives for FP/GP anesthesia re-entrant training. Arduous on-call requirements, geographic and professional isolation, and lack of affordable and available anesthesia locum relief make it difficult for them to leave their communities for continued medical education (CME) or vacations. These factors, combined with the lack of anesthesia mentorship and supports in the system, were noted to be important contributors to early family physician burn-out from anesthesia practice.

The third subtheme, “And so We’ve got a Two-tiered Maternity System,” (Box 2C) described participants’ perceptions of women’s access to epidural pain relief during childbirth in their hospitals. Anesthesiologists in large community hospitals described relatively replete obstetrical anesthesia services and, although they covered other assigned services while on-call from home after hours, they had the capacity to provide services within reasonable time limits. Participants from large community hospitals described administration of labor epidural pain relief within an hour, on average, from time of request, pointing out that other anesthesiologist colleagues while often “in house” after hours covering the needs of other services and might be able to help out. The availability of obstetrical anesthesia services in small town and rural communities, however, varied significantly between communities. Participants described that labor epidural pain relief was simply not available in some communities. In other communities, there was a 4–6 h delay following maternal requests due to competing needs of other services or inaccessibility after hours. Physicians practicing in small town and rural hospitals with low epidural rates described that women (particularly multiparous) seeking epidural pain relief simply choose to deliver outside of their communities. All rural hospitals in this sample provided Cesarean delivery coverage. Participants described that cases were triaged according to level of urgency and were attended with more or less difficulty based on the degree of anesthesia provider shortages, timing of the request, and co-existing demands for services on a given day.

Key issues and barriers to obstetrical anesthesia care

This second theme captured the barriers encountered by participants during provision of obstetrical anesthesia services in their primary hospitals of practice. It was comprised of three sub themes. The first was “Caught in the Middle” (Box 3A). Participants in large hospitals and small town and rural hospitals pointed out that the unpredictable nature and low volume of obstetrical anesthesia services requirements meant that these services were provided ad hoc and according to level of urgency by physicians assigned to other anesthesia services. Participants explained that this method of covering these services made sense from an efficiency and remuneration perspective, but it left them struggling to attend to simultaneously occurring needs for coverage of Cesarean deliveries and epidurals. Participants also mentioned that cross-coverage sometimes led to interpersonal difficulties with surgeons whose elective surgical lists in the operating room were being interrupted to cover maternity ward needs.

Box 3 Key issues and barriers to obstetrical anesthesia care
Full size table

Local Barriers to Obstetrical Anesthesia care (Box 3B) was the second subtheme. Anesthesiologists and FP/GP anesthetists described the variety of barriers they encountered as they attempted to update obstetrical anesthesia practices. Regardless of size and location, some barriers were common across hospitals. These included the lack of time and the shortage of hospital infrastructure supports required to develop ‘best practices’ obstetrical anesthesia protocols. They also included the shortage of interdisciplinary human resources and the lack of access to the interdisciplinary education packages required for uptake of best obstetrical anesthesia practices. Participants indicated that resistance to change was often encountered across the various professions (e.g., nursing, pharmacy) involved in peripartum care and often undermined successful implementation of new “best” obstetrical anesthesia practices. Local hospital culture and negative caregiver attitudes, which, according to participants’ descriptions, varied considerably between hospitals, were also described as important barriers to women’s access to epidural pain relief.

The third subtheme, Lack of Access to Obstetrical Anesthesia Resources within the Greater System (Box 3C), described the variety of ways in which anesthesiologists and FP/GP anesthetists believed lack of access to anesthesia resources within the system magnified local barriers to obstetrical anesthesia care. Physicians from across the sampled spectrum of hospitals described the difficulties they encountered in obtaining obstetrical anesthesia protocols and, in particular, the difficulties in obtaining educational resources from centers of obstetrical anesthesia excellence within the system for in-service training of interdisciplinary team members. Anesthesiologists in large community hospitals described the need for a central resource for information, describing their frustration at the inefficiencies involved in “re-creating the wheel” in every hospital. While they lacked time and infrastructure supports to create and implement practices, they had far greater capacity than physicians practicing in small town and rural communities. Family practitioner anesthetists described that lack of resources and time left them with little capacity to develop and implement best practices protocols for local use. They expressed a need for ongoing connectivity with obstetrical anesthesia mentorship to assist them in modifying the protocols designed for use in larger centers to meet the requirements of their rural resource-poor communities. Family practitioner anesthetists further voiced their need for access to obstetrical anesthesia expertise, advice, and consultation during difficult obstetric cases, for access to technical skills updates (epidural retraining or training), if necessary, and for provision of CME more suited to their specific learning requirements and practice context. Family practitioner obstetrical anesthetists explained that the absence of such mentorship supports, particularly in obstetrical and pediatric anesthesia, was an important contributor to early “burn out” and cessation of FP/GP anesthesia practice in rural communities.

A multi-faceted but context-specific solution is required

This theme included two sub themes and described solutions proposed by participants. The first subtheme related to The Need for Formal Knowledge Exchange Networks between Obstetrical Anesthesia Centers of Excellence and Community Hospitals (Box 4A). Participants from across the spectrum (university-based obstetrical anesthesia teaching to rural remote Ontario) of hospitals described, in a variety of ways, that anesthesia networks would be the best solution to meet the needs of community hospitals for knowledge transfer. They proposed that uptake of “best practices” obstetrical anesthesia care would be best facilitated if these relationships were formalized, funded, and geographically based according to existing clinical care alignments (if present), providing linkages between mentorship and interdisciplinary educational supports in centers of excellence and the spectrum of community hospitals across the province. Participants indicated that such networks could be used to facilitate consultation with mentorship, skills updates, team training, and ongoing CME (via telemedicine, onsite, and offsite teaching), as well as facilitate efficient and timely uptake of best practices protocols. Networks were also described as potential sources for locum relief in rural remote areas.

Box 4 A multi-faceted but context-specific solution is required
Full size table

The second subtheme was FP/GP Anesthetists are the Answer to the Anesthesia Human Resources Shortage in Small and Rural Hospitals in the Periphery (Box 4B). Family practitioner anesthetists explained that anesthesiologists did not commonly desire work in their small and rural communities and that use of anesthesia assistants, anesthesia extenders, or nurse anesthetists made little sense in their low anesthesia case volume context. They shared concerns that anesthesia extenders and assistants would only further dilute their anesthesia skills and do little to address their need for independent coverage of both anesthesia and family medicine “on-call” duties. Participants voiced their beliefs that FP/GP anesthetists provided the best solution to the anesthesia shortage in their communities, citing their medical training, their ability to efficiently and cost effectively multi-task and provide “on-call” coverage for a variety of much needed family medicine services, and the existence of long-established training programs for FP/GP anesthetists in Ontario. To answer staffing needs in peripheral hospitals, participants expressed the need for additional training slots for FP/GP anesthetists, improved incentives for family physicians desiring re-entrant positions anesthesia training, and novel methods of increasing locum anesthesia pools. Family practitioner anesthetists described that a minimum of four physicians were required to maintain 24/7 coverage of obstetrical anesthesia services in small and rural hospitals.

Discussion

This health services study focused on key issues and barriers encountered by physicians providing obstetrical anesthesia care in Ontario hospitals with delivery volumes of fewer than 2,000. Numerous significant stressors were identified. Overall, these were greatest in small and rural hospitals and among FP/GP anesthetists. Some barriers, however, were commonly described by providers across community hospitals, regardless of delivery volumes, hospital size, or location. These included lack of time, resources, and hospital infrastructure supports required to develop and implement “best practices” protocols as well as difficulties arising from lack of dedicated anesthesia staffing in labor and delivery suites.

Other barriers more specific to practice in the periphery included worsening FP/GP anesthesia shortages, lack of CME suited to rural practice context, the need for better access to anesthesia mentorship, the need for suitable environments for skills updating and retraining, and professional isolation. All of these obstacles further magnified difficulties experienced by anesthesiologists in large community hospitals in the distant north and by FP/GP anesthetists. FP/GP anesthetists in small rural communities described provider isolation and an inability to access obstetrical anesthesia mentorship and resources in the system as important barriers to care. Although FP/GP anesthetists also looked to anesthesiologists in large nearby community hospitals for technical skills updating and retraining, providers from these hospitals described limited capacity to perform this role due to heavy clinical loads and lack of time in our larger study.11

While anesthesiologist shortages were described in large northern Ontario hospitals, these providers described continued capacity to provide full obstetrical anesthesia services coverage in their hospitals; this was not the case in many small and rural communities where FP/GP anesthesia staffing shortages led to reductions in services availability. Physicians in small and rural hospitals described a variable and unpredictable capacity for obstetrical anesthesia care on a day-to-day basis, often with little capacity to cover more than most urgent and emergent cases. Family practitioner anesthetists described worsening shortages that, if left unchecked and without remedy, might threaten continued capacity for Cesarean deliveries in some communities. Loss of Cesarean delivery capacity has been noted to be an important contributor to closure of rural maternity services.15

Also, labor epidural pain relief in many small and rural communities was regularly delayed beyond limits deemed acceptable in larger centers or was simply not available despite providers’ best efforts. Our findings, along with those from other work examining labor pain relief with parturients,16 support suggestions that reductions in availability of labor epidural pain relief is contributing to the urbanization of low-risk maternity care in Ontario.2 Urbanization further dilutes rural provider skills, further jeopardizes the availability of local services, and creates additional expense and stress elsewhere in the system. More than 50% of maternity beds in higher acuity urban Ontario hospitals are occupied by low-risk pregnancies,2 forcing higher-risk pregnancies to be transferred elsewhere, including out of the province. It should be noted, that, although labor epidural rates are generally lower in smaller hospitals, their use has steadily increased in some regions of Ontario since 2003.7,17,18 Whether this implies an increase in anesthesia providers in some areas of the province or an increasing strain on limited anesthesia resources is not clear.

Community anesthesiologists from hospitals with 2,000 or more deliveries (larger provincial study), those from hospitals with fewer than 2,000 deliveries, as well as FP/GP anesthetists described difficulties in establishing the required ongoing linkages with obstetrical anesthesia mentorship and resources for advice and support and uptake of best practices. Difficulties, however, were greatest among FP/GP anesthetists in small and rural communities, who described little local capacity to develop, modify, or implement uptake of “best practices” without additional resources and mentorship from the system. For anesthesiologists in large community hospitals with more than 2,000 deliveries, the challenging issues were related generally to their lack of time to develop best practice protocols, to bring them through hospital committees, and to attend to the interdisciplinary team training required.11 Providers from university to rural remote community hospitals described the need to develop, over a period of time, formal funded geographically based knowledge transfer networks between community hospitals and university-based hospitals to support evidence-based changes in practice across the system. Family practitioner anesthetists expressed that networks might also lead to improved FP/GP anesthetist retention, lessen FP/GP anesthesia “burn out” in rural areas, and provide a platform to build strategies that could better address locum staffing and anesthesia CME needs.

Despite the difficulties encountered, FP/GP anesthetists were described as the “best answer” to the medical provider shortage in small and rural communities, and participants indicated that anesthesia extenders and assistants made little sense in their practice setting. Participants described the need for increased dedicated funding for FP/GP anesthesia training and re-entry training positions in university-based anesthesia teaching programs. They also described the need to address disparities between rural communities in funding obstetrical anesthesia services and the need to re-address under-serviced grading to permit more distant rural communities to attract and retain FP/GP anesthetists.

Study limitations include the absence of participants from hospitals where maternity services had already been closed. Physicians from these centers might have provided additional valuable insight into the “human” factors associated with closures. Closures have also been associated with reductions in staffing as well as hospital cost-saving measures.5 In addition, the information obtained in this study may not be applicable to all obstetrical anesthesia providers in community hospitals in the “periphery,” although participants from all regions of Ontario were interviewed.

Overall, our findings suggest that the issues faced by anesthesia providers in the “periphery” are complex, require solutions at many levels, must be context-specific, and to be effective, must also simultaneously address the greater issues surrounding the provision of anesthesia services within these communities. Lastly, our findings should not be divorced from greater issues that appear to exist at the health “systems” level. These include the need to recognize the important roles played by anesthesiologists and FP/GP anesthetists in maternal and newborn care and safety and to ensure anesthesia representation in national and provincial health human resources planning, in high-level interdisciplinary maternal newborn advisory panels and in interdisciplinary teaching programs aimed at risk management and quality assurance in maternity units. Increased surveillance of services provided and associated outcomes are also needed. These deficiencies are only beginning to receive the attention they need in order to better develop, provide, and sustain safe high quality maternal newborn care in Canada.5,19