Rural maternity care

Guideline Developer(s)

Society of Obstetricians and Gynaecologists of Canada

Date Released

2012 Oct

Full Text Guideline

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Foreign Language Translations

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

High-quality maternity care to women who reside in rural and remote communities

Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the Society of Obstetricians and Gynaecologists of Canada (SOGC).


Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Medline was searched for articles published in English from 1995 to 2012 about rural maternity care. Relevant publications and position papers from appropriate organizations were also reviewed.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

This joint position paper has been prepared by the Joint Position Paper Working Group. Building on the 1998 Joint Position Statement on Rural Maternity Care, this enhanced document includes new evidence. Acknowledging that interprofessional care of women through the continuum of prenatal, intrapartum, and postnatal periods is the norm, this paper represents the collaboration between not only physician organizations but also nursing and midwifery organizations.

Cost Analysis

Impact of the Loss of Maternity Services

When rural maternity services are lost, women are required to travel to ensure adequate access to maternity care providers and services. Financial costs almost always include accommodation and food in the referral community, often for a month or more in the period before and after the birth of the child. Additional financial costs include loss of income and travel costs if the partner wishes to be present at the birth of the baby, arrangements for other children who may need to remain at home, and the cost of phone calls to distant support networks. Studies in British Columbia have shown that women from some remote communities without maternity services spent an average of 29 days in the referral community at a cost of almost $4000 per person.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

This joint position paper has been approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada and approved by the Councils and/or Executives of the Canadian Association of Midwives, the Canadian Association of Perinatal and Women's Health Nurses, the College of Family Physicians of Canada, and the Society of Rural Physicians of Canada.

Identifying Information and Availability

Bibliographic Source(s)

Miller KJ, Couchie C, Ehman W, Graves L, Grzybowski S, Medves J. Rural maternity care. J Obstet Gynaecol Can. 2012 Oct;34(10):984-91. [61 references] PubMed


Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Joint Position Paper Working Group

Composition of Group That Authored the Guideline

Principal Authors: Katherine J. Miller, MD, Almonte ON; Carol Couchie, RM, Garden Village Nippising First Nation ON; William Ehman, MD, Nanaimo BC; Lisa Graves, MD, Sudbury ON; Stefan Grzybowski, MD, Vancouver BC; Jennifer Medves, RN, PhD, Kingston ON

Joint Position Paper Working Group: Kaitlin Dupuis, MD, Nanaimo BC; Lynn Dunikowski, MLS, London ON; Patricia Marturano, Mississauga ON; Vyta Senikas, MD, Ottawa ON; Ruth Wilson, MD, Kingston ON; John Wootton, MD, Shawville QC

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Society of Obstetricians and Gynaecologists of Canada (SOGC) Web site. Also available in French from the SOGC Web site.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 19, 2013.

Copyright Statement

The NCG summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.




Guideline Category


Clinical Specialty

Family Practice
Internal Medicine
Obstetrics and Gynecology

Intended Users

Advanced Practice Nurses
Health Care Providers
Physician Assistants

Guideline Objective(s)

To provide an overview of current information on issues in maternity care relevant to rural populations

Target Population

Women who reside in rural and remote communities in Canada who are or could become pregnant

Interventions and Practices Considered
  1. Access to integrated perinatal care system
    • Access to surgical and anaesthetic services
    • Consider women's social and emotional needs
  2. Collaborative care and rural maternity team
    • Registered nurses
    • Appropriate remuneration for maternity care providers
  3. Practitioners skilled in neonatal resuscitation and newborn care
  4. Training for rural maternity health care providers
  5. Quality improvement and outcome monitoring
  6. Patient safety and continuing professional education
Major Outcomes Considered
  • Quality care to women in rural areas
  • Perinatal mortality, morbidity, and intervention rates
  • Rates of adverse outcomes
  • Personal cost


Major Recommendations

Introduction and Background


  1. Women who reside in rural and remote communities in Canada should receive high-quality maternity care as close to home as possible.
  2. The provision of rural maternity care must be collaborative, woman- and family-centered, culturally sensitive, and respectful.
  3. Rural maternity care services should be supported through active policies aligned with these recommendations.

Levels of Service


  1. While local access to surgical and anaesthetic services is desirable, there is evidence that good outcomes can be sustained within an integrated perinatal care system without local access to operative delivery. There is evidence that the outcomes are better when women do not have to travel far from their communities. Access to an integrated perinatal care system should be provided for all women.

Impact of the Loss of Maternity Services


  1. The social and emotional needs of rural women must be considered in service planning. Women who are required to leave their communities to give birth should be supported both financially and emotionally.

Collaborative Care and the Rural Maternity Team


  1. Innovative interprofessional models should be implemented as part of the solution for high-quality, collaborative, and integrated care for rural and remote women.
  2. Registered nurses are essential to the provision of high-quality rural maternity care throughout pregnancy, birth, and the postpartum period. Maternity nursing skills should be recognized as a fundamental part of generalist rural nursing skills.
  3. Remuneration for maternity care providers should reflect the unique challenges and increased professional responsibility faced by providers in rural settings. Remuneration models should facilitate interprofessional collaboration.

Newborn Care


  1. Practitioners skilled in neonatal resuscitation and newborn care are essential to rural maternity care.

Training for Rural Maternity Care


  1. Training of rural maternity health care providers should include collaborative practice as well as the necessary clinical skills and competencies. Sites must be developed and supported to train midwives, nurses, and physicians and provide them with the skills necessary for rural maternity care. Training in rural and northern settings must be supported.
  2. Generalist skills in maternity care, surgery, and anaesthesia are valued and should be supported in training programs in family medicine, surgery, and anaesthesia as well as nursing and midwifery.
  3. All physicians and nurses should be exposed to maternity care in their training, and basic competencies should be met.

Patient Safety and Continuing Professional Education


  1. Quality improvement and outcome monitoring should be integral to all maternity care services.
  2. Support must be provided for ongoing, collaborative, interprofessional, and locally provided continuing education and patient safety programs.
Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Staying Healthy

IOM Domain



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