Background
Rural communities globally have unique and specific needs which come to the fore in the experience of childbirth. The clinical significance of maintaining sustainable maternity services in these communities has been demonstrated [
1]. For the woman and her family and the health professionals who deliver rural maternity care there are interwoven personal, professional and organisational relationships to be navigated. These relationships are integral to maternity care [
2‐
6] and are particularly pertinent in rural maternity care provision [
7,
8]. This paper reports on an aspect of a larger study examining rural maternity experiences from a variety of professional and user experiences in New Zealand [
9]. The theme of relationality resonated throughout the data of this study as a key component of safe care and is the focus of this paper. The study was undertaken within a well-resourced and established healthcare infrastructure. Review and discussion of the literature is therefore focused on similar regions.
New Zealand has a unique maternity system based upon continuity of care. Most care is provided by Lead Maternity Care providers (LMCs) who are mainly self-employed midwives with some GPs and obstetricians taking on this role. The Ministry of Health directly funds LMCs, who are either a midwife or a doctor (e.g. GPs) with obstetric qualifications [
10]. Over the years, most GPs have discontinued providing maternity services leaving LMC midwives as the main providers [
11]. When the LMC is not available rural based New Zealand GPs are called upon to assist with maternity care and emergencies not required in urban areas [
12]. Women choose from available LMCs in their region for pregnancy, birth and postnatal care; although choice is often limited to one care provider in a rural situation. Such care is free to citizens and residents of New Zealand. The maternity service also employs core midwives who provide hospital based midwifery services to women when they are inpatients. LMCs are responsible for coordinating women’s maternity health care from early pregnancy until 6 weeks postnatally, this includes full intrapartum care [
13]. They provide primary services as well as provide care to women in secondary services if they are booked with them.
The LMC through ongoing assessments will decide in partnership with the woman if referral or not is required to other services. For example if a woman and infant have straightforward antenatal, birth and postnatal experience then the LMC makes no referrals to medical colleagues. LMC midwives work across the full scope of their practice within referral guidelines and are accountable for the decisions they make. The referral guidelines for consultation with obstetric and related medical services list the conditions for referring women or their infants to specialists or other primary caregivers. The guidelines are evidenced based and agreed by midwives, obstetricians, other health care specialists and consumers [
14]. These guidelines are reviewed and updated at least every 5 years. The delivery of maternity services in New Zealand is underpinned by the requirements of the national Section 88 Maternity Notice regulated by the Ministry of Health [
10]. These institutions oversee the service and payments of primary maternity care provision.
Rural New Zealand communities are diverse with small populations living over large geographical areas [
15]. Defining what is rural is complex and there remains no consensus on what constitutes rural health care [
16,
17]. It has been suggested that researchers define and name rural as pertinent to the project and select or formulate an appropriate definition [
18]. Informed by personal experiences, discussion with rural health care providers and examination of national New Zealand policy documents and international definitions the definition of remote rural for this study is:
A locality in which experiences of maternity occurs 60 min or more by road (in optimal weather conditions) from secondary hospital services as determined by those that live and/or work in these regions who have local knowledge of actual lived travel times.
Most maternity care in these regions is provided by rural LMC midwives working in isolation [
11]. The skill set and qualities required for maternity care providers in rural areas has been shown to be similar to urban colleagues; yet significantly different. Being confident and making autonomous decisions and knowing when to call for back-up are essential [
7,
19‐
24]. An ability to work inter-professionally and collaboratively has also been highlighted as essential in rural practice [
7,
20,
22]. It is apparent that these skills require relationships inter and intra-professionally and collegial communication pathways with necessary supplementary skills and resources. Some of these relationships may be within community and ideally face-to-face whilst others are at a faraway distance where the rural midwife may be unknown to the person on the other end of the phone. It can be surmised that the experience of providing and receiving maternity care in rural areas is very different to urban areas of New Zealand. However there is a paucity of research on how relationships influence safety, nurture satisfying practice for rural maternity care providers and what promotes positive experiences for mothers and families in rural regions. This paper reports on a study that reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care.
Methods
The rationale for using a qualitative methodology for this study was based on the need to gather data that provided in-depth and rich stories of the lived experience of rural maternity. Bearing witness to the stories in these regions has value providing an opportunity to review, reflect and inspire new thinking.
Interpretive hermeneutic phenomenology guided the approach to data collection. Unstructured in-depth interviews with women and rural health care providers were conducted making it possible to reveal further understandings of the meaning of rural maternity experiences. The focus of this approach is the surfacing of meaning from lived experience descriptions bringing insights that gesture to our shared humanness [
25]. The ontological literature provides an avenue into in-depth exploration of ‘being-with-other’ and ‘being-in-the world’ as found in the writings of Heidegger. His interpretation of ‘being’ gives the foundation to further interpretation [
26]. Further, the work of Gadamer is drawn upon to show how language itself can ‘speak us’ and how the text itself interacts with the investigator, through the ‘fusion of horizons’ or perspectives [
27,
28].
In-depth interviews of one to 2 hours with families, midwives, GPs and ambulance staff in a range of remote/rural areas in New Zealand were undertaken. A total of 13 interviews were conducted following signed consent in a place suitable to participants in the regions in which they lived. Participants were asked to share their experiences of rural maternity care. Although there were prior indicative questions, participants were able to take the discussion in directions that were important and significant to them whilst ensuring that key research questions were addressed. The method was largely informed by van Manen [
25,
29]. Interviews were transcribed and analysed using a phenomenological approach for themes and patterns that highlighted areas that spoke to us as being important. Lived experienced descriptions from these manuscripts were edited into crafted stories and then analysed [
30,
31].
Pre-understandings
All meanings are informed by fore-structures of understanding that are culturally, socially and environmentally constructed. It is important to reveal our pre-understandings and judgements as they shape the questions brought to the study and interpretation that followed [
28].
Susan was the principle investigator. The majority of her practice career had been in the primary sector with a particular focus on rural midwifery. She has worked in several remote rural locations as a midwife in Europe, developing countries and in New Zealand. She was interviewed by her co-author, Liz, prior to the start of this study in order to highlight her own pre-understandings and judgements. Liz, long ago, had an experience of practising in a remote mission hospital in the developing world, and has visited many remote communities. They shared an understanding of birth in situations where there is no immediate support. Susan’s own stories of practice in rural New Zealand were rich in joy, but the exhaustion, fear and burden shone through. We came to this study both in awe of women’s ability to birth ‘naturally’ but at the same time very mindful that things can go wrong, quickly. We believe in the ideal world women have a right to give birth close to their own community.
Recruitment of participants
Purposeful sampling by word of mouth was used to recruit study participants from the South and North islands of New Zealand. Professional and social networks were used to initiate interest. Participants were recruited by a process of snowballing. A letter of invitation and information sheet was sent once a potential participant had signalled an interest by telephone, email or a third person mutual contact. Care was taken to prevent coercion. Non response to the formal invitation was an easy way for people to opt out of this study. Participants not included were women and/or partners experiencing some degree of depression following birth, health care practitioners involved in complaint proceedings, present students of AUT University (where the principle investigator was working as a senior lecturer) and no one under Susan’s professional midwife care at the time of the study.
All 13 participants are volunteers. They all have an interest in the phenomenon. They all live and work within different rural regions of New Zealand and come from a variety of cultural, professional and social backgrounds:
-
3 × Mothers
-
6 × Midwives: Registered practising midwives
-
3 × Ambulance crew (paid and unpaid)
-
1 × General Practitioner Obstetrician
Crafted stories from the raw transcriptions were returned to participants for their critique. Participants were thus able to ensure that the crafted stories reflected their experiences as narrated in the interview. Due to the complexity and sensitive nature of data gathered in small population regions, constant efforts were made to ensure anonymity as much as possible. Names, places and institution identifying features were removed from the crafted stories. Several participants wanted details of stories removed or changed to ensure they would not be identified. This did not alter experiential meaning that surfaced from the data or diminish the emergent themes found in the data overall. Each participant was provided an agreed pseudonym. All responses were treated confidentially to protect the privacy of participants. Transcriptions were conducted by a professional transcriber who signed a confidentiality form.
Interpretive analysis
Analysis was done using an interpretive hermeneutic phenomenological process involving a process of writing and re-writing in which stories were crafted from the raw interview data and then analysed for meaning [
32]. The interpretive analysis of the stories required a dialectic movement between all the stories and the detail of individual stories involving cycles of thinking-writing-reading until a plausible thematic argument emerged [
25,
29]. Through moving between parts and whole of crafted stories, and all stories together, themes emerged and new horizons of understanding surfaced as clusters of stories revealed commonalties and resonant qualities. Reading and re-reading the whole captured the core significance bringing to light the phenomenon of New Zealand rural maternity experience. Exploration of historic and contemporary New Zealand, and international literature from midwifery and other relevant disciplines, was incorporated within the project in order to provide context. The purpose of analysis is to provide rich uncovering of the phenomenon in order to provoke further thinking and call to action. Phenomenology does not claim to reveal everything there is to know about phenomenon; this is not possible.
Ethics approval was obtained prior to recruitment and data collection. Ethics approval was gained through AUTEC reference No. 15/18 on 9th February 2015. Approval included a researcher personal safety protocol.
Discussion
Each maternity service and subsequent experience reflects the geographic, social, political region in which it has grown and the blend of skills locally available. Some qualities may seem constant yet they are never static and permanent. They are in constant play; day to day, person to person, region to region, and situation to situation. The qualities presented here do not have defined permanent boundaries, nor are they binary opposites of negative or positive, good or bad. On the contrary there is blurring within the tensions of what works and what constrains. That is the nature of human lived-experience. Acknowledging this plasticity reveals the continuous tensions at play within rural maternity.
This study reveals how rural communities are comprised of people in an interweaving tapestry of connectivity. Relationships matter in rural regions yet there are tensions at play within these relationships. Whilst congenial, supportive relationships are ideal, there were stories of breakdown. The data shows that when a relationship break down the consequences of poor communication is revealed as discord. Participants in this study were clear that functioning relationships with others in their community and those at the interface of secondary services were what made things work. The significance and meaning of relationships (personal and professional) becomes more apparent when absent or when discord is experienced. The limited choices as to whom one needs to rely on in small rural community may serve to magnify potential for discord. The importance of collegiality, or working together in a manner in which trust and mutual respect are built is vital in rural regions. Living with discord is feeling disharmony, unrest and unsettledness bringing a mood of anxiety into practice.
Relationships revealed themselves as essential to sustaining a sense of support. Heidegger tells us that we are never without others [
26]. The rural maternity practitioner is always with others; if physically alone in a crisis the absence of help from another makes the aloneness even more stark. Relationships matter and are woven throughout maternity care [
2,
34,
40,
41]. This is particularly pertinent in rural and remote regions when secondary services are far away. When working with others (far and near) is difficult or not possible, rural maternity experience is vulnerable. When relationships far and near are strong and reciprocal, safe maternity experience becomes safer and more enjoyable. Unfortunately it is evident in this study that not all relationships function as they should and could.
Notwithstanding personal differences there is always the tension that some relationships ‘happen of their own accord’ and others that must be ‘made to happen’ to keep practice safe and sustainable. For example, in the moment of pondering who to call for help, the ‘who’ is likely to sway the willingness to make such a call promptly. Anticipating a respectful response brings a very different mood to making such a decision as opposed to a sense that one will be judged, censured and belittled. A starting place to forging collegial relationships is understanding the need to get to know each other and thereafter offer support.
Within every story from participants, palpable moods emerged. Heidegger makes it clear that understandings unfold within moods. It is the moods of a particular place, national and regional politics, systems, persons and events that underpin our understanding of how we act within what is being experienced [
26,
42,
43]. Heidegger describes how moods or attunements are not merely passing personal feelings or emotions but are intrinsically a part of the shared experience of Being-in-the-world. Attunements are thus not necessarily private [
44]. Moods can be social and public and represent ways of Being-with-one-another. They provide a sense of collective and personal experience of how a situation is unfolding and how we are faring. A shared mood is therefore a public shared communication that reveals the situated experience of rural maternity. A mood of vulnerability, as expressed by several of the participants, permeates beyond the midwife herself; as, in contrast, does a mood of strong team support.
Pre-understandings provoke moods. When the discourse of one discipline is dis-respectful of another discipline (and vice versa) such pre-understandings go ahead of us shaping the moment of ‘now’ [
28,
44]. Rural midwives work within their world, rural GPs within their world and hospital staff within theirs. Each professional group brings their own pre-understandings and mood to practice. Focussing on differences, the binary conflicts, issues of power and perceived subjection are important to acknowledge yet can be limiting and do not open to possibilities. Dichotomous thinking is a product of a society that thrives on arguments and wanting to win a position [
45]. It infers that there are rigidly marked partitions in discordant voices with little recognition of a middle ground within which common meanings and significance can begin to be understood.
Sustainable rural maternity requires a focus and way of attuning that reaches beyond the confines of individuals and professional groups - this is not a new idea. Robertson argued for a more collaborative model in rural New Zealand maternity [
46]. Divergent approaches arguably only weaken the strength and flexibility required in rural maternity relationships. Conversely, convergence of differing professional and personal approaches highlights the tensions within experiences and discloses what matters most.
Despite obvious differences something connects us in every moment. Exploring what matters most in rural maternity via multiple vantage points reveals that all involved want the same; safe positive outcomes. Each participant does what they do for the sake of what matters most to them. For Heidegger, the fundamental comportment of human beings to the world is care. How we enact that care is through concerned actions that discloses what matters most to us. The desire to care and actualise concerns into actions is an aspect of being-with others revealed through relationships. Participants find themselves in the world of rural maternity ‘concernfully’ dealing with what matters most to ‘them’. They trust that carrying out their unique professional responsibilities and their own set of concerns will achieve the best outcomes for mothers and infants in their communities. Yet it is the bringing of different voices to this interpretation that allows the diversity and commonality to be seen.
The importance of appreciating the differences in history of traditions cannot be underestimated. Gadamer tells us that differences in traditions can become understood more profoundly by appreciating pre-understandings and lead to a fusion of interpretive horizons previously unspoken [
28]. Hunter and Segrott [
47] showed how achieving midwifery professional autonomy through adoption of a model of care created defined boundaries between midwifery and obstetric colleagues leaving doctors excluded and undervalued. Similarly New Zealand midwives return to autonomy in 1990 resulted in a loss of GP control over primary maternity care [
13] and continues to influence current professional relationships. As Gadamer [
28] explains; ‘It is the tyranny of hidden prejudices [pre-understandings] that makes us deaf to what speaks to us in tradition’ (p. 272). Lampert [
48] contends that it is our responsibility to make familiar that which seems alien and conversely make alien that which seems familiar. In this reflexive move it becomes possible to highlight and appreciate the distances between traditions (e.g. professional groups within maternity) and foster healthier relationships.
Coming to know and trust each other’s commitment to the client builds confidence between maternity care providers and enables a move forward to a place that works for everyone. This entails Midwives and GPs for example finding ways of working closely together that would be ‘unheard of’ in the urban areas. Drawing attention to our pre-understandings reveals what matters most, safe positive childbirth, and opens the possibility of an enjoyable community of rural maternity practice. Achieving safe positive childbirth experiences and resilient thriving rural communities is a possibility worth pursuing. This requires working co-operatively and not competitively, changing the mood across rural maternity services to one of trust and lessening any feelings of vulnerability. Exemplary communication and nurturing of collegial relationships is crucial.
There is a place in our shared human experience when knowing and understanding brings us into relationship with each other. When this occurs rural maternity care practitioners and maternity system decision makers attune to what matters most and nurture relationships that foster safe care for ‘this’ woman and ‘this’ baby; not personal, professional and organisational discord. Attuning to being-with-other starts with the gift of a helping hand, sharing of time and local resources, congenial conversations and a listening ear when needed. These simply ways of being-with build affable and congenial relationships that enable our concerns to translate into doing what needs to be done ‘now’ together. According to Heidegger it is not possible to verify attunements or moods but we can draw attention to them and awaken them [
43]. The stories in this paper gesture a need to unpack what shapes pre-understandings to build such authentic open dialogue and awaken a mood of trust. All need to be heard to affect lasting optimal changes in these regions where a point of vulnerability can lead to catastrophic breakdown. People, whatever their role and wherever they live and work want to feel appreciated (loved), they need to feel understood and feel safe [
49].
It is not possible to “make” everyone get on with everyone in their locality, but it is possible to reduce issues that cause much of the discord. When professional tensions are put aside to ask “what is the care this client needs and how best can we collectively provide such care?” it is likely that creative solutions that work in everyone’s best interests will be found. Recognition of the need to attune collectedly, of being-with-others in ways that enable trusting connections that traverse differences and nurtures reciprocal understandings is essential.
It is vital not to view rural maternity as inherently problematic. Rural maternity globally is a dynamic environment that is often reported as innovative [
50]. Despite myriad challenges rural maternity providers are continually reported as providing safe maternity care [
51]; this is no less true in New Zealand [
23]. Nevertheless this study uncovers struggles in relationships that challenge sustainable, safe and integrative rural maternity services.
At times it appears that rural practitioners carry the weight of responsibility alone; held within the confines of a single professional group culture. False dichotomies, battles, conflicts, territorial disputes and boundary protection strategies appear to impede the quality improvements for individual and community. Good communication and collegial rapport as described above are key to ensuring integrated maternity services that maintain the safety of mothers and babies between remote and secondary urban services [
52,
53]. Hierarchical structures that dictate how relationships are allowed to happen are not useful and can impede progress. Each individual and collective experience needs valuing [
54]. Struggling relationships in rural regions due to the constant need for negotiating myriad complexities, social influences and risks inherent in rural regions has been identified previously [
55]. Collaboration and cooperation is thus needed whilst acknowledging professional agendas, local risks and complexities.
All maternity care providers, whatever their discipline, are reliant on others. Respectful collegial working relationships at the interface of services and mutual appreciation of each other’s context, skills and expertise are vital. The rural maternity experience is reliant on clear open professional and friendly communications with others across maternity health care teams despite differences in location and ways of working. In one region in this study ambulance crew and GPs met regularly to discuss recent transfers and how they were managed. It was unfortunate that the local rural midwives were not included. It was not clear why this was the case. Inviting local midwives into multi-disciplinary meetings would be one simple initiative that promotes collaborative learning, debriefing and support.
Fostering better collaborative learning in remote rural regions with GPs, midwives, nurses and ambulance crew would be advantageous. Inter-professional learning opportunities are recommended as a means to build feelings of credibility and confidence in each other’s roles [
56]. Sharing such events may break down feelings of discord and help with collaboration across sectors. It has been found that such collaborative workshops develop appreciation of others’ skills and areas of responsibilities and allow the possibility of cohesive common understandings and contextual meanings [
56]. This process would engender transformative learning and a reflexivity that brings understanding of what it would be to stand in each other’s shoes. Although such initiatives remain rare [
57], they are worthy of exploration and could facilitate more cohesive communities of rural practice.
Strengths and limitations
This is a small New Zealand study and is focussed on producing findings that are not generalisable, but are potentially transferable. The context of the study is a well-resourced high income region and acknowledges the different range of complexities in low to middle income countries. Achieving trustworthiness and ensuring conclusions were plausible and credible was essential in maintaining integrity and dependability of this study [
58]. The study is balanced through integration of human voices and philosophical notions. The chosen methodology enabled the voices of those living in, and living through, the daily contextual realities of New Zealand rural maternity to be heard. This permits discussion and recommendations that are derived from the lived experiences of the phenomenon. There are always more voices and further interpretations. For example the voices of core staff receiving rural mothers and their maternity health care providers on transfer would be valuable. Likewise the voices of family members of health care providers and mothers are absent from this study. Openness was demonstrated through the use of a detailed audit trail and concreteness was established through presentation of pre-understandings and justification of the study. Resonance has been shown through sharing and discussing findings providing reassurance of plausibility and the study has been actualised through acceptance for peer reviewed publications and presentations. In addition the study and subsequent report has been checked against the COREQ reporting framework [
59].
Hermeneutic phenomenology acknowledges that there is no final truth but a pointing to what is happening. There is always more to interpret from the data in any study of this nature; we offer our plausible interpretations providing opportunity for a way forward into further research, thinking and practice development. Although there is safety in a formulaic recipe to fix things it must always be contingent on the flux of practice reality that is lived in and lived through.