Models of maternity care in rural environments: barriers and attributes of interprofessional collaboration with midwives.

OBJECTIVES: interprofessional primary maternity care has emerged as one potential solution to the current health human resource shortage in many developed nations. This study explores the barriers to and facilitators of interprofessional models of maternity care between physicians, nurses, and midwives in rural British Columbia, Canada, and the changes that need to occur to facilitate such models.
DESIGN: a qualitative, exploratory framework guided data collection and analysis.
SETTING: four rural communities in British Columbia, Canada. Two rural communities had highly functional and collaborative interprofessional relationships between midwives and physicians, and two communities lacked interprofessional activities. PARTICIPANTS: 55 participants were interviewed and 18 focus groups were conducted with midwives, physicians, labour and delivery nurses, public health nurses, community-based providers, birthing women, administrators, and decision makers.
FINDINGS: in models of interprofessional collaboration, primary maternity care providers - physicians, midwives, nurses - work together to meet the needs of birthing women in their community. There are significant barriers to such collaboration given the disciplinary differences between care provider groups including skill sets, professional orientation, and funding models. Data analysis confirmed that interprofessional tensions are exacerbated in geographically isolated rural communities, due to the stress of practicing maternity care in a fee-for-service model with limited health resources and a small patient caseload. The participants we spoke with identified specific barriers to interprofessional collaboration, including physician and nurses' negative perceptions of midwifery and homebirth, inequities in payment between physicians and midwives, differences in scopes of practice, confusion about roles and responsibilities, and a lack of formal structures for supporting shared care practice. Participants expressed that successful interprofessional collaboration hinged on strong, mutually respectful relationships between the care providers and a clear understanding of team members' roles and responsibilities. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: interpersonal conflicts between primary maternity care providers in rural communities were underpinned by macro-level, systemic barriers to interprofessional practice. Financial, legal, and regulatory barriers to interprofessional collaboration must be resolved if there is to be increased collaboration between rural midwives and physicians. Key recommendations include policy changes to resolve differences in scope of practice and inequitable funding between rural midwives and physicians.