Chapter 8: Organization of services

Table of Contents

• Acknowledgements
• Introduction
• 1. Regionalization of Maternity Services
  • 1.1 Importance of Local Care
  • 1.2 Out-of-Hospital Birth
  • 1.3 Integration of Support
  • 1.4 Tiers of Service
• 2. Improving the System
  • 2.1 Policies and Procedures
  • 2.2 Education for Health Care Providers
  • 2.3 Best Evidence and Clinical Practice Guidelines
• 3. Service Delivery Level Accountabilities
• 4. Personnel Requirements
• 5. Interprofessional Care
• 6. Transport
  • 6.1 Regionalization and Transport System Structure
  • 6.2 Essential Components of a Regional Referral and Transport Program
  • 6.3 Decision Making for Maternal Transport
  • 6.4 Maternal Transport Policies and Procedures
  • 6.5 Neonatal Transport Policies and Procedures
  • 6.6 Transport Personnel
  • 6.7 Telemedicine
• 7. Facilities and Equipment
  • 7.1 Phases of Care
  • 7.2 Design Principles and Design Process
  • 7.3 Hospital births: Prenatal, Antepartum, Birth, and Postpartum Facilities
  • 7.4 Home Births and Birthing Centres
  • 7.5 Metrics for Facility Design Evaluation
• 8. Implementing the Guidelines: Facilitating Change
  • 8.1 Patient–client Engagement
  • 8.2 Supporting the Culture of Family-Centred Maternity and Newborn Care
• 9. Evaluation of Care
  • 9.1 The Importance of Continuous Quality Improvement
• 10. Planning for Pandemics
  • 10.1 Pop-up Maternity Units
  • 10.2 Considerations for Hospital-based Care
  • 10.3 Health Care Provider Considerations
  • 10.4 Patient–client Considerations
• Conclusion
• References

Acknowledgments

Introduction

The guiding principles of family-centred maternity and newborn care (FCMNC) provide the basis for national, provincial, regional, and local planning and organizing of maternal and newborn services. These principles state that pregnancy and birth are normal, healthy life events and family support, participation, and informed decision-making are central to all care. Care is organized in such a way that it responds to the physical, emotional, psychosocial, and spiritual needs of the woman, the newborn, and the family.

Care begins with attitudes and practices that value and respect women and trans or non-binary people, children, and families, and focuses on the many environments influencing the family, including the social, psychological, spiritual, and physical environments. Family-centred maternity and newborn care (FCMNC):

• Applies to all care environments;
• Recommends and enables care as close to home as possible;
• Encourages early parent–infant attachment as this is critical for newborn and child development and the growth of healthy families;
• Cares for the psychological needs of women and their families;
• Respects the diversity of people's lives and experiences;
• Recognizes the impact of racism on health and health care;
• Recognizes that discrimination against vulnerable families occurs;
• Incorporates informed decision-making;
• Functions within a system that incorporates ongoing evaluation.

To achieve these goals, the organization of services can take into account:

• All stakeholders when planning and providing care, including parents, community groups, community agencies, health care providers (HCPs), public health units, and hospitals;
• The pregnant women's health status (prior to and during pregnancy), and referral to the appropriate resources for care;
• Provision of accessible care, with consideration given to the family's geographical, demographic, and cultural conditions.

Responding to population needs, as informed by best available evidence, is vital in the planning and organization of care. Planning and organizing maternal and newborn services requires taking into account:

• Canada's size and low population density;
• The different needs of Indigenous communities;
• The shifting HCP mix through the attrition of family physicians providing maternity care and the growing contribution of midwives.

1. Regionalization of Maternity Services

The regionalization of health services in Canada took place in response to the persistent need to contain costs, a changing health care workforce, continued demands for services, and an aging population. Through regionalized health care, health planners anticipated meeting the more complex health care needs of rural residents in geographically proximal communities (regional referral centres) as opposed to large urban tertiary centres. The aim of this is to reduce the need to travel long distances and the associated disruptions. In addition, the policy objective of maternity care closer to home can be maximized for all aspects of care including preconception, the prenatal period, labour and birth, and the postpartum and newborn periods.

It is important to organize regionalized perinatal care so that women and families can access appropriate, safe and quality care as close to home as possible. The guiding imperatives behind regionalized perinatal care are decentralized services overseen by regionally defined governing bodies embedded in tiers of service that correspond to population needs. In this model, perinatal services without access to local caesarean birth function well in communities with a small number of births per year. In these communities, pregnant women are supported by both family physicians and midwives, and most of whom have uncomplicated pregnancies allowing for local birth. Also, in many rural settings in western and northern Canada, family physicians with enhanced surgical skills perform caesarean births, with the support of specialists in regional referral centres. Specialist involvement is required in larger populations where the absolute number of caesarean births is higher and complexity of care is also greater.

In a healthy, well-balanced system, the capacity of the maternity services aligns with the capacity of the site to appropriately care for the newborn. Case selection based on local resources is core to regionalized perinatal care, assuming that risk-associated triage is performed. Pregnant women with maternal or fetal risk factors are referred to facilities with more resources.

From a family-centred perspective, regionalized health care reduces the stress of having to relocate to a referral community for low-risk vaginal birth, improves outcomes, and begins to address the calls to action of the Truth and Reconciliation Commission. These calls to action have paved the way for actioning local birth as a cultural mandate and a part of the reconciliation process. ^{Footnote 1}

Although the benefits of regionalized maternity care are built on the assumption that primary maternity care is available in or close to rural communities, the lack of stability of smaller maternity sites has made this difficult to achieve. This instability has been precipitated by difficulties in recruiting and retaining HCPs to work in low-volume sites that often have no local access to caesarean birth. Although maternity services without local access to caesarean birth are safe—assuming appropriate case selection for local birth, regional support of rural HCPs, and access to efficient transport, should it be needed—the last two decades have seen a worldwide lack of provider sustainability in low-volume sites.^{Footnote 2},^{Footnote 3},^{Footnote 4} A notable exception to this in Canada are services in the North, where provider levels have been maintained over many decades. ^{Footnote 5}

Effective and efficient transportation is essential in those instances when greater levels of care are needed in a timely way. The Society of Obstetricians and Gynaecologists of Canada (SOGC) Maternal Transport Policy describes regional transport systems, including the equipment and personnel to facilitate safe and effective transfer if required, and the need for 24-hour availability of transport systems and reliable and accurate communication between referring hospitals and transport teams. ^{Footnote 6}

Although clear transport protocols are relevant through all levels of tiers of service, the need is greatest for transport from sites with low levels of resources (e.g., without local access to caesarean birth or on-site specialist care). Across Canada, 40.5% of rural women experienced travel time to a hospital longer than an hour. ^{Footnote 7}

Effective transport planning and implementation requires a holistic perspective, one that takes into account the health consequences of delayed access to appropriate levels of care and the impact of transport out of a local community or away from an expected location on the birthing family. Such transport often results in increased stress and anxiety, particularly when it is urgent and leads to separation of the family at a time of heightened vulnerability. When pregnant women need to leave their community prior to the onset of labour, they are often separated from partners and family for extended periods. This may be due to the limited capacity of emergency transport to accommodate a woman's chosen support and lack of financial resources for family members to travel privately. In some instances, family members may need to stay behind to work or look after other family members.

Transport with a supportive family member is both clinically and psychologically optimal for the birthing woman. A family-centred planning paradigm works to put in place structures that mitigate the effect of required travel from the home community (e.g., subsidized accommodation in the referral centre that can support family members; travel subsidies beyond those available through Indigenous Services Canada's Non-Insured Health Benefits Medical Transportation Policy Framework for eligible registered First Nations and recognized Inuit clients), keep families together, and facilitate timely return to their home environment.^{Footnote 8}

Planning regionalized maternity care is based on unique community needs and geography to reduce pregnancy complications that may occur due to travel when relocating for access to care services. Health care resources can be directed in ways that are most productive, under the organization and guidance of provincial and territorial ministries and departments of health. Well-functioning regional maternity care also promotes the participation of the community in making health services–related decisions.

1.1 Importance of Local Care

Regionalized perinatal care, underscored by the importance of responsiveness to community need, has not played out in all jurisdictions across Canada as originally intended. Many rural areas have seen maternity services centralized, as opposed to regionalized, and the dissolution of low-volume services in their community. High outflow maternity services, where more than two-thirds of the population leave the community for care, may lead to:^{Footnote 9},^{Footnote 10},^{Footnote 11},^{Footnote 12}

• The damaging cycle of fewer local births in an already low-volume setting, either because of clinical indications or because of maternal or family preferences;
• Diminished confidence of HCPs, which may reflect back to communities as lack of support for local birth, further encouraging patient–family outflow and challenging sustainability;
• A relationship between adverse maternal and newborn outcomes and distance to services;
• Health and psychosocial effects on pregnant women and their families, including in Indigenous communities where birthing on traditional land supported by extended family and community can be essential to care.

Appropriate care in the prenatal and postpartum periods also requires careful planning through a regional lens to ensure appropriate screening and triage for birthing women and newborns. Women with no complications of pregnancy can be comprehensively cared for by local HCPs or visiting primary care physicians or midwives. Referral to a specialist, if needed, can be facilitated through virtual care. But it is vital that women in communities without antepartum care have a plan to relocate either before or at the onset of labour and that they and their newborns have appropriate care in the postpartum period. All birthing families also need access to prenatal information and education. When in-person prenatal classes are not possible, virtual classes and written material can enhance family learning.

1.2 Out-of-Hospital Birth

An essential part of regionalized maternal and newborn care is support for out-of-hospital births attended by registered midwives. The SOGC recommends risk assessment using established criteria in either a home setting or a birthing centre, as both locations are suited for birthing women likely to proceed with a normal vaginal birth.^{Footnote 13} Recognizing and supporting out-of-hospital birth with a regulated HCP ensures that triage, referral, and transportation to a greater level of care are in place across the regionalized system should transfer be necessary.^{Footnote 6}

1.3 Integration of Support

A key determinant of safety in regionalized maternal and newborn care is the support for primary HCPs by other providers, such as specialists or sub-specialists.^{Footnote 4} Well-functioning, integrated tiers of services may be conceptualized as relationships, with sites with fewer resources depending on the backup and support of sites with more resources. The sites with more resources, in turn, offer support because they trust in the judgment of the services with fewer resources.^{Footnote 14}

Virtual communication has become increasingly important in health care with HCPs accessing on-demand consultation with other centres. For example, in British Columbia, four real-time virtual support (RTVS) pathways have been established using Zoom for Healthcare licences. One of the four pathways, MaBAL, for rural physicians with expertise in maternal and newborn care can be reached "24/7 through Zoom and by phone to provide guidance on urgent and non-urgent preconception, prenatal, antenatal, intrapartum, and postpartum presentations, for both moms and newborns".^{Footnote 15}

The concept of these networks is not new. They have historically characterized triage across rural Canada, but are now intentionally implemented to formalize and optimize referral and support pathways.^{Footnote 16}

1.4 Tiers of Service

Although maternity care is similar across many jurisdictions in Canada, the provincial/territorial mandate for health service delivery means that developing a national classification system for tiers of service is a challenge. The SOGC recently recommended "the adoption of one national standardized set of definitions to encompass all facilities providing maternity care for different levels of anticipated risk."^{Footnote 17} Currently, only British Columbia and Ontario have developed tiers of service for maternity care in Canada.^{Footnote 18},^{Footnote 19} The American College of Obstetricians and Gynecologists (ACOG) have refreshed their consensus statements on Levels of Maternal Care, and this framework could have applications to the Canadian context.^{Footnote 20}

Following the philosophical foundation of advancing tiers of service corresponding to population complexity, the SOGC consensus statement Attendance at and Resources for Delivery of Optimal Maternity Care describes levels of service and criteria of the various levels of care.^{Footnote 17}

British Columbia's Tiers of Service and Ontario's Standardized Maternal and Newborn Levels of Care Definitions further explain the levels of acuity and complexity that each level of service can safely support.^{Footnote 18},^{Footnote 19} Expanding capacity to support complex perinatal needs through generalist, specialist, and sub-specialist care maximizes efficiency in meeting anticipated local needs while centralized sub-specialist care aligns resources most effectively to address less common complexities. Research has shown that sub-specialist centres are not optimal for the care of birthing mothers who are at low risk.^{Footnote 21}

2. Improving the System

2.1 Policies and Procedures

An effective response to changing circumstances and emerging evidence is best achieved when policies and procedures towards a safe birthing environment are written, then regularly reviewed and updated. At a local level, all facility staff members should be able to easily refer to and provide input to these policies and procedures.

Written policies and procedures can be about:

• Communication about the care and support of women, infants, and families;
• Referral practices between agencies/services;
• Admission of women, infants, and families to hospitals and birthing centres;
• Assessment and criteria for discharge of women and babies from hospitals and birthing centres;
• Criteria for home birth;
• Referral to community services/supports;
• Identification and referral of women and/or infants in current or potentially abusive situations;
• Emergency transfer of mothers, babies, and support people, where possible, including the requirement for prior arrangements with a receiving health facility in the event of an emergency;
• Newborn resuscitation;
• Breastfeeding promotion, protection, and support;
• Maintenance of health records;
• Infection control and biohazard precautions including Level 4 pathogen and pandemic plans and responses;
• Storage of medications and emergency drugs;
• Hazardous materials and workplace safety practices;
• Responses to maternal/newborn emergencies;
• Evaluation of care and quality improvement;
• Internal disaster procedures, including in the case of fire;
• Cultural safety and health equity, including anti-racism and the elimination of discrimination against marginalized and vulnerable groups and people.

In addition, Accreditation Canada has developed Obstetrics Services standards to help organizations assess quality at the point of service delivery.^{Footnote 22} These standards are based on a culture of quality, safety, and family-centred care.

2.2 Education for Health Care Providers

Ongoing learning by HCPs is essential as new evidence for best practices continues to emerge. Oversight of professional development and skills maintenance is generally the combined responsibility of professional colleges and individual practitioners. Whereas some of the specific competencies and behaviours needed are delineated by professional colleges, others reflect the needs and standards of the clinical care unit or agency.

Optimal learning opportunities are multidisciplinary, with all care team members participating—that is, physicians, midwives, nurses, social workers, nutritionists, lactation consultants, respiratory therapists, perinatal psychologists, and others. Three principles outlined in Chapter 1 are important components of education for all health care professionals delivering FCMNC:^{Footnote 23}

• A holistic approach to maternal and newborn care (Principle 6);
• Collaboration between care providers (Principle 7);
• Consideration of maternal and newborn care best practices from global settings that may be relevant to a Canadian context (Principle 17).

Education topics—ideally identified at the team level—may include:

• New treatments;
• Clinical concerns;
• Research evidence or emergent situations that affect care;
• Cultural safety, anti-racism, and non-discriminatory, respectful, and psychosocially sensitive care education.

Opportunities for learning may include inter-disciplinary rounds, workshops, conferences, learning packages, formal undergraduate and graduate education programs, distance learning, self-study, or participation on new committees or in new projects or research. Regional administrators will want to consider the challenges that rural and remote HCPs may face if travel out of their community is difficult. Coordination of educational efforts through organized regional programs ensures consistency of information and reduces duplication of efforts. Increasingly, facilities and agencies are using virtual learning through online classes, conferences, and meetings.

2.3 Best Evidence and Clinical Practice Guidelines

HCPs can tailor guidelines to the needs of individual patient–clients.^{Footnote 23} Deciding about transport and referral is ideally based on "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."^{Footnote 24} In this way, care achieves the Institute for Healthcare Improvement Quadruple Aim: optimal patient–client outcomes, patient–client satisfaction, provider satisfaction with care, and cost efficiency.^{Footnote 25}

Beyond improving clinical quality, guidelines are an effective way to organize and present the increasing volume of evidence HCPs face.

3. Service Delivery Level Accountabilities

Although facility standards are provincially and territorially regulated across Canada, researchers and health planners increasingly recognize the need for a common framework to ensure quality of care and facilitate evaluation.^{Footnote 26} However, only British Columbia and Ontario have published expectations for capabilities in maternal–newborn care. These publications include guidelines defining maternal and newborn levels of care, human resource requirements, and diagnostic tests and treatments.^{Footnote 27},^{Footnote 28}

The commonalities between jurisdictional models align with consensus definitions such as those of the American College of Obstetricians and Gynecologists (ACOG) Standards of Obstetric-Gynecologic Services.^{Footnote 29} Recognizing the competencies required to safely support birth at home and in rural centres without local access to caesarean birth varies across Canada. Support for both these models of care is based on evidence on safety of care, an appreciation of Canada's vast geography and the recognition of the psychosocial consequences of relocating for birth.

The SOGC supports women with low-risk pregnancies giving birth in rural and remote communities. The Society states that "risk assessment is not a once-only measure but a process continuing throughout pregnancy and birth. Referral of the woman to a higher level of care may be required when signs of complications become apparent".^{Footnote 30} Despite a national endorsement of such services, rural Canada has seen a precipitous decline in local health care due to resourcing challenges.

Perinatal care in Canada is based on a regionalized system of service delivery for both maternal and newborn care. Hospitals with local caesarean birth capacity provide referral backup for those without such capacity, and larger centres provide increasingly specialized care based on population needs. In facilities that do not offer caesarean birth (that is, birth centres and level I hospitals), key preconditions to care include informed discussions about the limitations in emergency situations; transport and other potential consequences of limitations in emergency situations; established obstetrical backup should it be necessary; on-site availability of medications to manage obstetrical emergencies; and medication to treat postpartum hemorrhage.^{Footnote 13} Refer to the SOGC consensus statement Attendance at and Resources for Delivery of Optimal Maternity for expected capabilities by level of service.^{Footnote 17}

4. Personnel Requirements

Families in Canada receive intrapartum care from a variety of health practitioners, including obstetrician–gynecologists, family doctors, nurses or nurse practitioners, and midwives. According to the Vanier Institute, nurses make up the largest group of maternity care providers in Canada.^{Footnote 31} The 2018 Perinatal Nursing Standards in Canada articulated four standards to which perinatal nurses are expected to adhere.^{Footnote 32} These standards support and endorse the principles of FCMNC, including relationship-based care, interprofessional collaboration, quality and safety, and evidence-informed practice.

Staffing decisions affect clinical outcomes as well as provider satisfaction and retention.^{Footnote 33},^{Footnote 34} Evaluation of the impact of nurse staffing mandates on patient–client outcomes in California and on hospital outcomes in 15 European countries shows that lower nurse-to-patient ratios significantly affect surgical mortality and failure-to-rescue rates.^{Footnote 35},^{Footnote 36} However, models of staffing for surgical units may not be appropriate for perinatal units, as their staff-to-patient ratios are based on the different care needs.

Recommendations on minimum staffing levels are generally based on new mother–newborn care being without complications, but all mother–baby dyads do not need the same level of nursing care. Postpartum ratios in particular can range from 1:1 to 9:1, depending on the level of care required for any complications^{Footnote 37}. The Association of Women's Health, Obstetric and Neonatal Nurses recommends the following patient-to-nurse ratios for perinatal care for healthy mother–newborn dyads:^{Footnote 38}

• One nurse to one woman for women labouring with minimal to no pharmacological pain relief or medical interventions;
• One nurse to one woman for women receiving oxytocin;
• One nurse to one woman with labour complications;
• Two nurses to one woman for vaginal and caesarean birth—one nurse for the mother and one nurse (with newborn resuscitation capabilities) for the baby;
• Two nurses up to 2 hours postpartum—one nurse for the mother and one nurse for the baby, or in the case of multiples, one nurse for each baby.

An indicator comparing nurse-to-patient ratios across Canada is currently not available. The Canadian Institute for Health Information (CIHI) is working to fill this gap by developing a nationally comparable, systematic method of measuring the number of patient–clients cared for per staff member.^{Footnote 39}

In addition to provider-to-patient ratios, the experience and skill mix of nurses is a key factor in perinatal staffing. Standardizing nurse-to-patient ratios in Canada might protect nurses from excessive workloads, but it might also prevent departments making independent decisions about staffing based on factors such as the availability of human resources and individual nursing skill and comfort levels.^{Footnote 40} In predicting personnel needs for births and postpartum care, factors to consider include different staffing models and patient–client needs in urban and rural hospitals. As noted earlier, mother–baby dyads in tertiary hospitals in urban centres are more likely to require higher levels of care than their counterparts in low-risk only birthing centres.^{Footnote 37} In small rural hospitals where resources are limited, the need for flexible staffing may not allow for the same nurse-to-patient ratios as implemented in higher-resource settings.^{Footnote 41}

Midwives are playing an increasingly important role in maternity care in Canada, offering a wide range of services and working with other medical professionals as needed. Care by a midwife of mothers and babies at low risk is cost effective and associated with shorter hospital stays and fewer interventions.^{Footnote 42} Also, midwifery-led care may improve birth outcomes for vulnerable women with low socioeconomic status.^{Footnote 43},^{Footnote 44}

Midwifery regulation and health care delivery vary significantly between jurisdictions in Canada.^{Footnote 45} Some provinces and territories have been regulating and funding midwifery for over 20 years, with the colleges of midwives the regulatory bodies that provide standards and guidelines for the profession.^{Footnote 46} In other jurisdictions, the profession remains unregulated and unfunded.^{Footnote 46}

Given that the perinatal period is characterized by significant biological and psychosocial changes, administrators will want to consider how staffing and coordinating allied health professionals and ancillary personnel can complement the work of primary HCPs to provide comprehensive and integrated family-centred care. The SOGC's Attendance at and Resources for Delivery of Optimal Maternity Care identifies appropriate resources, personnel, and facilities to encourage safe physiological birth in a family-centred environment in rural and urban communities. This consensus statement is built on an appreciation of birthing women's autonomy in making informed decisions "even in difficult situations when health care providers disagree with the choice."^{Footnote 17}

The consensus statement also recognizes the adverse psychological and sociocultural consequences of requiring birthing mothers to leave their community.^{Footnote 17} It urges HCPs to consider not only the health of the women and their babies but the psychosocial risks when selecting appropriate locations for birth. In addition, the statement calls for adopting a national, standardized set of definitions for all facilities providing maternity care based on their capacity to care for varying levels of risk. This would allow for a national framework for evaluation.

5. Interprofessional Care

Multidisciplinary collaborative maternity care teams are important in sustaining the overall availability of HCPs and improving access to and choice in maternity care in Canada.^{Footnote 47}

In 2006, the SOGC led the Multidisciplinary Collaborative Primary Maternity Care Project with the objective of developing guidelines, determining national standards, and increasing collaboration between professionals.^{Footnote 48} Recommendations included that decision makers and other key stakeholders commit to developing coordinated care, advocate for the resources required to support appropriate care, and reach a consensus on key strategies to establish, retain, or expand multidisciplinary collaborative maternity services.^{Footnote 48}

The project identified key principles to a collaborative model:^{Footnote 48}

• Quality, woman-centred maternity care, based on equity of access to and integration of services;
• Based on best evidence and practice guidelines;
• Professional competence with commitment to the collaborative model and mutual trust and respect;
• Shared values, goals, and visions, with honest, open, and continuous communication;
• Responsibility and accountability including the acceptance of the need to discuss financial issues;
• Effective, integrated regional provision of services to include locally based care with knowledge of available services.

This model aligns closely with FCMNC through common, articulated principles and through recognition of the importance of community consultation in developing locally-responsive models of care. The principles note specifically the unique challenges in low-volume rural settings: "In rural areas the challenge is less one of size and inter-relationships and more the enduring questions regarding access to and availability of care, and who provides that care. It is well known that the rural hospital closures and downsizing occurring across the country is placing new challenges on maternity care providers."^{Footnote 48},p.26

Since access to perinatal services varies across communities, many jurisdictions do not have standard protocols for sharing information about patient–clients with providers. This can result in missed referrals, inconsistent messaging, and a lack of coordinated care.

Two pilot communities in the Northern Health authority in British Columbia have established an integrated service model using practice support coaches and care process coaches to help bridge primary care practice with other services in the health authority. These communities have reported increased and improved access to primary care for prenatal service, including for vulnerable pregnant populations who subsequently receive evidence-based care for the remainder of their pregnancies and onwards.^{Footnote 49}

Other studies that evaluated integrated hospital and community models of perinatal care have reported increased screening for and treatment of perinatal mood and anxiety disorders (PMADs).^{Footnote 50},^{Footnote 51} Standardization of processes related to the coordination of perinatal care led to a reduction in risk factors across the social determinants of health and overall improved quality of care through clinical and professional integration.

The SOGC consensus statement The Roles of Multidisciplinary Team Members in the Care of Pregnant Women (2016) prioritizes the safety and interests of the patient–client while respecting their autonomy and maintaining respect for all team members.^{Footnote 52} The consensus statement highlights the importance of defined roles and responsibilities within teams and the importance of addressing barriers to successful collaborative care.

6. Transport

The process of evacuating pregnant or birthing women from rural and remote areas was developed through the 1960s and 1970s, in response to a perceived lack of safety in low-resource settings. Efficient and timely access to emergency transport for women and their newborns is essential for safe regionalized care. However, the stress of separating from family and losing community connections and the potential for financial hardship on leaving the community can have deleterious effects.^{Footnote 5} The trauma of relocation has led to some women concealing pregnancy until they are in labour, often at the cost of access to prenatal care and screening.

Sensitivity to the family's view of transport together with strategies to meet acute clinical needs can lead to improved care. In many rural Indigenous communities, local birth has been reclaimed through community midwifery programs.^{Footnote 53},^{Footnote 54} Nevertheless, there are instances when higher levels of care are necessary, requiring culturally safe transportation.^{Footnote 55} In 2017, Indigenous Services Canada instituted funding for escorts for rural Indigenous birthing women, mitigating some of the effects of isolation due to relocation.^{Footnote 56}

If the health of the newborn is a concern, outcomes are better if the transport occurs during pregnancy.^{Footnote 57},^{Footnote 58},^{Footnote 59},^{Footnote 60} Despite the clinical advantages of caring for high-risk cases in appropriately resourced centres, the effect of transport on the family needs to be considered.^{Footnote 61} The stress of relocating from familiar settings, the loss of a known care provider, separation from supportive family and community members, and the financial costs of accommodation and travel are additional stresses for both the birthing mother and her family.^{Footnote 62} To this end, the most effective mitigation strategy is for HCPs to try to identify high-risk pregnancies and births early enough in the prenatal period to avoid urgent transport.

There are also times when, because of work or the need to care for other children, family escorts may not be available. This can result in the birthing mother feeling isolated and alone, which can further exacerbate her concerns for the health of her baby. The principles of FCMNC that underscore best practices are grounded in the importance of keeping families together through accompanied transport. Recognizing that there will be times when this is not possible, HCPs and administrators can work to mitigate the consequences of this stress.

Essential components of effective family-centred transport include:^{Footnote 59}

• Clear and honest communication about the health status, prognosis and anticipated interventions required to optimize the health of the birthing mother and her newborn;
• Presence of family members during stabilization and transport (if possible);
• Continuous, professional support given to the family;
• Including the family in care planning and decision-making;
• Ongoing communication from the referral site on the status of the mother and baby if the family is separated.

6.1 Regionalization and Transport System Structure

The regionalization of maternal and newborn care is based on maximizing access to and capacity of neonatal intensive care units (NICUs).^{Footnote 61} Two related goals of regionalized perinatal care include:

• Expedient identification of high-risk pregnancies to ensure birth at a hospital with the appropriate level of care;
• Speedy recognition of high risk not identified during prenatal care in order to efficiently transport infants to a more appropriate level of care.^{Footnote 63}

The key to successful regionalized perinatal care is therefore the identification and timely transport of at-risk pregnant women.

Best practices for efficient transport include a single access point and provincial/territorial coordination to prioritize needs based on clinical acuity and the integration of transport modalities (air and ground).^{Footnote 64} Single-call dispatch within a formalized network of patient–client transfer also increases provider satisfaction.^{Footnote 65},^{Footnote 66} In addition to streamlined access, transport systems need to be able to offer medical advice, rapidly dispatch transport teams, and identify a receiving hospital.^{Footnote 59} In line with FCMNC, after the necessary care in a tertiary centre, maternal transport services also repatriate the mother and newborn, and families to sites close to home, as soon as possible.

6.2 Essential Components of a Regional Referral and Transport Program

The first component of an effective transport system is to avoid unanticipated or urgent transport. Ideally, high-risk pregnancies are identified before the onset of labour and the optimal place of birth is chosen based on anticipated resource needs. This is predicated on comprehensive care during the prenatal period and the full inclusion of birthing mothers and families in decision making. Despite efforts to mitigate the need for perinatal transport, there will be instances when unanticipated and urgent transport is required.

Because of the jurisdictional nature of Canadian health care, emergency transport mechanisms vary widely in terms of processes and infrastructure. Minimum criteria start with a well-resourced system with the sustained investment in regional health authorities.^{Footnote 67} Standardization of equipment, education, clinical competencies, and quality indicators is also necessary.^{Footnote 59},^{Footnote 68}

Adverse outcome mitigation strategies for reducing non-tertiary deliveries include a perinatal telephone advice line to optimize in utero transfers, and perinatal outreach education to providers at non-specialty perinatal centers.^{Footnote 68},^{Footnote 69},^{Footnote 70}

Designated emergency medical service (EMS) vehicles may need to be specialized. For example, use of dedicated vehicles by the four specialized transport teams across Ontario have been shown to decrease complications and optimize the quality of care for sick newborn babies.^{Footnote 71} Transport equipment should meet occupational health and safety standards for crew and the communications infrastructure used in smart phone, satellite phone, or webcam communication should be encrypted.^{Footnote 72}

At a systems level, the value of a no refusal policy is identified as a key intervention for improving care. A "no refusal policy" means a facility cannot refuse or deny the transfer of a patient–client needing critical care. Although the policy was developed based on trauma care, this mechanism of enabling timely triage is transferable to maternity care.^{Footnote 73}

6.3 Decision Making for Maternal Transport

Maternal transport can occur for many reasons: preterm labour; preterm rupture of membranes; severe gestational hypertension or other hypertensive disorder; antepartum hemorrhage; intrauterine growth restriction; inadequate progress in labour; malpresentation; and maternal trauma.

Transport is contraindicated if:

• The mother's condition is insufficiently stable;
• The fetus' condition is unstable and threatening to deteriorate rapidly;
• Birth is imminent; or
• Weather conditions are hazardous for transport.

Canada's vast area and varied climate means that urgent transport from a rural community may not be feasible and that the dangers of immediate transport outweigh expected benefits. Situational assessment is a key part of the decision-making process. Such assessment requires attention to weather and road or flight conditions, the health status of the mother and baby, her stage in pregnancy, the likelihood of imminent birth, and the availability of skilled HCPs.^{Footnote 72}

The key principles that underscore transport decisions include:^{Footnote 67},^{Footnote 72}

• The need to consult with specialists to determine whether transport is indicated for a high-risk pregnancy or birth based on risk factors for the birthing mother, the baby, the stage and progress of labour, and potential conditions en route;
• Communication between all team members including the sending and receiving HCPs;
• Supporting rural sites that may not have the resources to stabilize infants for long periods;
• Minimizing the number of transfers for the birthing mother or her baby;
• Avoiding transfers that separate the mother and her baby;
• The family's preference for relocation given the loss of existing social support networks.

While no national guides exist to help in obstetrical and neonatal transport decisions, Alberta Health Services have developed an "Obstetrical Transport Decision Tree" as part of their guideline Criteria to Support Appropriate Level of Obstetrical Care.^{Footnote 72}

6.4 Maternal Transport Policies and Procedures

Maternal transport plays an important role in ensuring that mothers in all regions have equitable access to the appropriate level of care for best mother and baby outcomes.^{Footnote 68} Barriers to successful transport of pregnant women include:^{Footnote 68}

• Lack of expertise in triaging pregnant women at high risk;
• Limitations of screening in populations at low risk;
• Lack of maternal transport capacity;
• Inflexibility in the criteria applied to assess referrals.

There are no Canadian national guidelines specific to maternal transport, which emphasizes the need for institutions to have written policies to follow when transferring and receiving a pregnant woman. The policies should describe:^{Footnote 72}

• Transport team members, skills required and responsibilities of both the sending and receiving sites;
• Transportation and equipment requirements;
• Mechanisms to measure quality assurance and system improvements;
• Communication and record sharing protocols.

Effective policies also emphasize a family-centred approach and include:

• Ongoing and open communication with the woman and her family about their circumstances so that they can actively participate in decision making;
• Continuous, supportive care from qualified personnel;
• Effort to keep family members together, with mechanisms in place for them to communicate with each other if they do have to be separated.

6.5 Neonatal Transport Policies and Procedures

Although best outcomes are achieved when transport occurs antenatally, some infants will inevitably need to be transported. As with maternal transport, it is critical that both the sending and receiving sites have in place policies and procedures to do with the transfer of a newborn. These would include describing the necessary personnel and equipment, communication, documentation, and sharing of medical documents (records, ultrasounds, blood tests). Having dedicated neonatal retrieval teams for transfer improves outcomes.^{Footnote 59}

Whenever possible, the newborn should be stabilized in the referring hospital prior to transport.^{Footnote 74} For neonatal stabilization, the Canadian Paediatric Society recommends that providers use Acute Care of At-Risk Newborns (ACoRN), an eight-step clinically oriented framework to gather and organize information, establish priorities, and intervene appropriately.^{Footnote 75} When deciding on a mode of transport, it is important to consider the physical stressors on the newborn. Newborns are particularly vulnerable to vibrations, and these need to be minimized during transportation to reduce further stress.^{Footnote 76}

The Canadian Paediatric Society recommends the following tools to use when making decisions about neonatal transport:^{Footnote 59}

Tool	Purpose
Mortality Index for Neonatal Transportation (MINT)	Produces a mortality prediction score for infants based on the information given to a retrieval service
Transport Risk Index of Physiological Stability (TRIPS)	Used to predict mortality at 7 days and overall using four weighted items: temperature, blood pressure, respiratory status, and response to noxious stimuli
Risk Score for Transport Patients (RSTP)	Differentiates infants requiring interventions en route from those who do not need these Has been proposed to aid triage
Situation, Background, Assessment, Recommendations, Read-back (SBARR)	Enhances communication and reduces errors Intended for use in hand-overs
Transport metrics recommended by the American Academy of Pediatrics and a Canadian initiative	Proposes expected transport times (mobilization, response, stabilization), noting that transport time depends on weather, distance, and mode of transportation, factors that are often out of the control of the transport team

The Canadian Paediatric Society's position Statement, The Interfacility Transport of Critically Ill Newborns, identifies components of a neonatal transport team, skills and training, equipment and vehicles, and systems and processes, emphasizing the importance of a family-centred approach to transfer. Refer to The Interfacility Transport of Critically Ill Newborns for recommendations on the personnel, equipment and vehicles, systems and processes, and quality assurance required to transfer newborns.^{Footnote 59}

6.6 Transport Personnel

Transport personnel require the collective expertise, technical skills, and clinical judgment to provide supportive care for the wide variety of emergencies that can occur during transport. Team members can include physicians, nurses, respiratory therapists, and emergency medical services (EMS), consistent with the expected level of need of the woman or newborn being transported.

For most transfers between hospitals, paramedics are the appropriate clinical care provider, but there are scenarios where, for clinical, logistical, and/or general supportive reasons, a midwife, physician, or nurse should travel with the patient–client.

In the case of neonatal transport, members of the transportation team require additional training to be able to stabilize the infant. If the infant has significant life-threatening instability, a neonatologist may accompany the transport team to help stabilize the infant.^{Footnote 77} The Canadian Association of Pediatric Health Care Centres (CAPHC) Competencies Profile - Interfacility Critical Care Transport of Maternal, Neonatal, and Paediatric Patients lists detailed competencies that cover a broad spectrum of requirements for clinicians engaged in transport.^{Footnote 78}

6.7 Telemedicine

Within a regionalized model of care, telemedicine can help reduce avoidable transfers by connecting specialists with patient–clients.^{Footnote 79},^{Footnote 80},^{Footnote 81} For example, telemedicine has been used to assess retinopathy of prematurity in very low birth-weight newborns; for fetal ultrasonography and echocardiography; and to support families and provide education.^{Footnote 82} Neonatologist consultations via telemedicine have resulted in fewer interfacility transfers compared to telephone consultations.^{Footnote 80} A majority (93%) of providers who piloted telemedicine technology reported improved patient–client safety or quality of care.^{Footnote 83}

These findings are particularly important for rural and remote community residents who may be able to avoid long distance transports to tertiary care centres as a result of increased integration of telemedicine into networks of care.

7. Facilities and Equipment

Although there are many ways to support FCMNC, the physical design of birthing facilities plays a key role. Birthing environments designed through a family-centred lens take into account the experiences and preferences of mothers and families. Facilities can meet the needs of women and families while achieving the overriding objective of safety for families and staff.

It is important to ensure, however, that the philosophy of care is primarily supported by the people who provide care. If changes to the physical facility are desired, they are best accompanied by efforts to support and sustain the practice of HCPs. Design decisions can impact teamwork in the context of care. The physical setting is as important as technology in facilitating communication. The culture of communication is supported by spatial transparency (the importance of seeing other employees); the creation of a collaborative and/or shared workspace; and neutral zones, that is, spaces that belong to everyone and neither create nor reinforce hierarchies (as is the case in doctors' rooms vs nurses' rooms).^{Footnote 84}

FCMNC principles are critical to consider when planning and organizing the physical facility. These principles recognize that birth is a celebration and, in most situations, a normal, healthy process. Women and families can be supported in a friendly, comfortable single-room environment, where they labour, give birth, spend time with their babies, and are cared for, together, without the disruption of moving from place to place or being separated from their newborn (known as single room maternity care, or SRMC).

The focus on maternal and newborn care has shifted towards improving quality of care.^{Footnote 85} This takes into account respectful and appropriate care and considers the family's satisfaction with their experience.^{Footnote 85},^{Footnote 86},^{Footnote 87} The provision of respectful maternity care is in accordance with a human rights–based approach to reducing maternal and neonatal morbidity and mortality. The World Health Organization (WHO) recommends:^{Footnote 88}

• Effective communication and engagement of all HCPs and administrators in response to women's needs and preferences;
• Interventions that aim to contribute to a respectful and dignified birthing experience.

This approach to dignified maternity care recognizes that:

• The central objective of care for women, babies, and families is to assist women in giving birth to healthy babies, with appropriate facilities and equipment;
• Caring for women is best done in the context of their families, and families can be comfortably accommodated in the environment and feel part of the process;
• When difficulties arise, a critical objective is to help families be together as much as possible;
• Technology needs to be used appropriately.

An integrated design process means involving the facility community in making decisions so that the priorities of the people using the facility–HCPs, staff, patient–clients–are at the centre of planning. This process is referred to as social design. Social design recognizes that families have diverse sociocultural needs, depending on the characteristics of the community and of the individual family.^{Footnote 89} Attention to diversity, through direct input, can lead to a tailored approach to the needs of the community. For many Indigenous communities, for example, birth is a collective experience supported by Elders and other family and community members during labour and after the birth. This requires enough space in the birthing room to respectfully welcome the woman's support people alongside HCPs.

Changing population characteristics can also factor into design decisions. A salient example is the rise in obesity rates in industrialized countries.^{Footnote 90} Design decisions that accommodate this trend include making sure an adequate number of beds, chairs, examination tables, blood pressure cuffs, and specialized equipment such as lifts are available to accommodate women living with obesity. Design should also consider the space required for women and their HCPs to navigate comfortably and safely and to accommodate other family members.

Ultimately, patient–clients value being met by "a welcoming homely space for themselves and their visitors that promotes health and wellbeing."^{Footnote 91}

Changing patterns in access to health care, namely the decreased length of hospital stay, also need to be taken into account when planning FCMNC.^{Footnote 92},^{Footnote 93} Design should reflect increased needs for antepartum and postpartum outpatient spaces. This may include private consultation or infant feeding locations near labour and birth units.

Although periods of new construction or major renovation are opportune for integrating family-centred processes and refreshing dated-looking facilities, existing spaces can also be improved using fewer resources. Examples include:

• Having showers for pain management instead of renovating to install birthing tubs;
• Using conventional hospitalbeds if no funds are available for special birthing beds;
• Using labour rooms for labour, birthing, and recovery;
• Expanding unit boundaries for walking during labour.

Other items, such as birthing balls, birth stools, rockers, sleeping chairs for partners, and decorative items that soften the environment, can be purchased at minimal expense. But design considerations extend beyond the birthing room to include continuous care, beginning with the birthing woman and family entering the facility.

Recognizing that FCMNC applies to all care environments, it is important to integrate family-centred design principles into all perinatal environments, including NICUs. In addition to meeting the newborn's physical needs, NICUs can support the psychosocial needs of the infant and their family.^{Footnote 94} In particular, design principles can help HCPs and families share the decision making and enable parents to be their baby's primary caregiver.^{Footnote 95} Single-family NICU rooms have a number of benefits, supporting families to make choices in the environment (by, for example, adjustinglighting, temperature, noise); improving rates of breastfeeding; and reducing parental stress and anxiety, particularly for those families that may be far from home for a prolonged hospital stay.^{Footnote 95}

Best practice standards for the design of a NICU also recommend a family library or education area, with information about NICU procedures, infant loss and grieving, and local resources.^{Footnote 96}

7.1 Phases of Care

Comprehensive maternal and newborn care encompasses a number of different phases. Facilities that incorporate such care can include a triage area for women who are not yet in active labour or are being observed to determine whether labour has begun. Some facilities will provide care for women requiring hospitalization during pregnancy, usually referred to as an antenatal unit.

According to guidelines established by Perinatal Services BC, the labour, birthing, and postpartum space is designed to avoid relocating the mother, utilizing SRMC. SRMC increases patient–client satisfaction, and can reduce infection rates, length of hospital stays, the number of staff positions, and direct costs.^{Footnote 97},^{Footnote 98},^{Footnote 99} Nurses have also expressed greater preference for single-room maternity care in terms of the physical settings, their ability to respond to family needs and teach families, the nursing practice environment, peer support, and perceived level of competency.^{Footnote 100} Their satisfaction was significantly higher than that of their colleagues in standard room settings. Although the goal of a complete hospital stay in a single room may not be possible for some existing buildings, reducing the number of relocations during a course of care could be achieved without infrastructural change.

If a caesarean birth is necessary, the woman is transferred to an operating room, and then returns to the same maternity/newborn unit.^{Footnote 101} Ideally, the operating room and recovery area are both within the maternal and newborn care area.

In the context of the COVID-19 pandemic, having a large number of single-family rooms in a NICU decreases the need for more restrictive parental presence policies, allowing families to stay together.^{Footnote 102}

7.2 Design Principles and Design Process

The functionality of space is determined by users or occupiers of that space. To enhance FCMNC, it is key to think about how women and families will experience the space. The following points are useful to consider:

• How do families find their way to the unit?
• What are the first impressions of families arriving at the hospital and on the unit?
• Is there adequate affordable parking next to the entrance? Is the walk-in entrance clearly marked?
• Does the unit have private areas where families can talk to staff, talk on the phone, or be together?
• Are there play areas for children?
• Is there a secure storage area for the family's belongings and dietary supplements (fridges, coffee/tea facilities)?
• Are there conference rooms, work areas, and lounges available for staff members?
• Are the surroundings warm and inviting? Is it clear that this is a place for families?

Mapping tools and three-dimensional (3D) modelling can maximize efficiencies in the design phase. Making a facility more family-centred without capital expenditure can be accomplished by carefully selecting interior colours, furnishings, finishes, and lighting to contribute to the comfort of the environment. In addition, facilities can incorporate relevant art work, murals, quilt work, and other decorative features that depict culturally diverse and inclusive representations of families. They may also offer services that promote FCMNC principles such as sibling tours and activities, nourishing snacks or meals as alternatives to food from the hospital kitchen, and personalized messages in families' rooms.^{Footnote 103}

Closely associated with a process for space design is the need for a change management plan to guide the transition from the existing space to the new environment and to encourage positive models of interaction between personnel and families in a new context. Although the physical layout of antenatal wards can encourage or hinder FCMNC, it is essential to recognize the influence of culture on such care and the importance of relationships as building blocks to a culture that encourages placing the birthing woman and her family at the centre of care.

7.3 Hospital Births: Prenatal, Antepartum, Birth, and Postpartum Facilities

Facilities that are 'patient-friendly' have easily accessible and usable layouts that allow for movement, communication, and connection between family members.^{Footnote 91} It is important to have adequate planning and space for independent and assisted wheelchair users throughout each of the antenatal, birth, and postpartum facilities.^{Footnote 105} Adequate storage space for handling aids, such as lifts and wheelchairs, is also needed.^{Footnote 106} Privacy is a very important aspect of care; it can be established and maintained through high levels of sound isolation and window drapes in all facilities.^{Footnote 106}

The International Health Facility Guidelines and the Canadian Health Care Facilities CSA Z8000-18: Planning, Design and Construction and other guidelines provide recommendations for the design and equipment in labour and birth units.^{Footnote 106},^{Footnote 107}

Recommendations for design and equipment

7.4 Home Births and Birthing Centres

Increasing access to midwifery care across Canada since 1992 has led to an increase in the number of home or out-of-hospital births attended by registered midwives. Home birth is safe for low-risk women likely to have uncomplicated vaginal birth.^{Footnote 121},^{Footnote 122} For some women, birthing at home may be the epitome of FCMNC, as labour and birth occur in a familiar and intimate environment attuned to the needs of the woman and her family.

Although each jurisdictional midwifery association has requirements, set in guidelines, for a safe home birth, there are few restrictions on the size of the home beyond having enough room for the birthing woman to lie down and for midwives to be able to assist her and set up their equipment.^{Footnote 123} A midwife will visit the home during the prenatal period to make sure it is suitable for a home birth and to determine the distance to hospital services and the best access for emergency medical services (EMS).

In some jurisdictions, out-of-hospital births can take place at birthing centres. These regulated community-based health care facilities support birthing for women at low risk of needing specialist support. Birthing centres may be free-standing or part of a larger health care facility. They are generally staffed by midwives, although in some jurisdictions physicians may also play a role. Many birthing centres are designed with open or multi-use spaces to facilitate labour and birth as well as individual and group prenatal care and postpartum, breastfeeding, and educational groups.

Birthing room décor may vary from home-like environments with wood furniture and standard double beds to a more institutional style that has hospital-grade furniture and beds. Many birth centres offer water birth. The design of birth centres is specifically targeted to be a counter-point to institutional settings or traditional hospital care.

7.5 Metrics for Facility Design Evaluation

Design decisions affect costs, operations, and performance, and effective design of health care facilities incorporates a sociotechnical approach; that is, one that combines human with technical elements.^{Footnote 124},^{Footnote 125} In recent years, Lean principles have been adopted widely in hospital design in order to reduce waste and fully utilize the capabilities of personnel.^{Footnote 124},^{Footnote 126} The "Lean 3P" (production, preparation, process) takes into account people, products, and processes in the design of facilities.^{Footnote 124} Lean principles include "understanding user value, mapping value-streams, creating flow, developing pull processes and continuous improvement."^{Footnote 84}, p.1 Two recent studies out of England applied these principles to the design of a new endoscopy unit and a new maternity ward.^{Footnote 124},^{Footnote 127} Both research teams found that 3P is an effective tool for developing facility designs that meet the requirements of multiple stakeholders.^{Footnote 124},^{Footnote 127}

The move towards evidence-based environmental design requires establishing metrics to evaluate the design. This includes tracking and evaluating the role of the physical design in clinical outcomes and improvements in indicators such as economic performance, employee productivity, and family satisfaction.^{Footnote 128} In addition to site-specific metrics, post-occupancy evaluations provide useful data to iteratively adapt the design to meet the needs of women and families.

Some jurisdictions are now mandating that health care redevelopment projects include a post-occupancy evaluation. Although such projects vary in terms of size, scale, location, and purpose, relevant evaluations can be standardized using toolkits.^{Footnote 129}

8. Implementing the Guidelines: Facilitating Change

Jurisdictions across Canada have shifted towards patient-and family-centred care as a way of increasing responsiveness to community needs in health care. Intended effects include improving measurable health outcomes, such as access to primary care; improving patient-client satisfaction with the care they receive; and reducing hospital wait times.^{Footnote 130},^{Footnote 131},^{Footnote 132} Explicit jurisdictional commitments to family-centred care is also taking place internationally.^{Footnote 133} These changes are supported by a restructuring process that prioritizes adapting the health care system to individuals' and communities' needs and preferences, rather than requiring people to adapt to the system. The core tenant is respect for people's values, preferences, and expressed needs.^{Footnote 134}

The following principles of family-centred care are particularly important to maternity care:

• Education and knowledge, on which care decisions can be made;
• Commitment to the family's full participation in decision making and in advocating for the birthing woman;
• Collaboration and team management to foster continuity through the care pathway;
• Sensitivity to cultural and spiritual dimensions of birth;
• Respect for patient–client needs and preferences to recognize individual values and beliefs;
• Access to information so that patient–clients participate in informed decision making;^{Footnote 135}
• An understanding that pregnancy and birth are normal physiological events that have the potential for pathologies and unexpected events;
• Recognition of the importance of meeting the psychological needs of women and their families throughout the childbearing year.

A culturally competent, family-centred care framework applies to three levels: the individual level, the hospital level, and the health care system level. The SRMC approach, for example, reflects best practices from the perspective of the mother and family. Prioritizing such process measures when evaluating care reinforces a family-centred perspective by re-framing the care pathway through the eyes of the mother and family.

8.1 Patient–client Engagement

Public engagement rooted in respect for patient–client voices in health care design and planning is one way to achieve family-centred care. Such engagement extends beyond capturing patient–clients' perceptions of care and involves the input of members of the public in strategic decisions about health services and policies.^{Footnote 136} Clear operational definitions of public and their role remains unclear. The public "wants input particularly in prioritisation processes across broad service areas, including development of the criteria on which funding decisions will ultimately be based", but there is a lack of a clarity of how citizens and patient–clients can contribute to this prioritization process and to transforming health care and improving maternity care.^{Footnote 93},^{Footnote 137},^{Footnote 138}

The widely used IAP2 Spectrum of Public Participation was developed to help define the public's role in any public participation process.^{Footnote 139} The continuum, representing categories of increasing impact on decision making, moves between activities to inform, consult, involve, collaborate, and empower citizens.

IAP2's Spectrum of Public Participation^{Footnote 139}

	Inform	Consult	Involve	Collaborate	Empower
Public participation goal	To provide the public with balanced and objective information to help them understand the problem, the alternatives, the opportunities, and/or the solutions.	To obtain public feedback on analysis alternatives and/or decisions.	To work directly with the public throughout the process to make sure that public concerns and aspirations are consistently understood and considered.	To partner with the public in each aspect of the decision making, including developing alternatives and choosing the preferred solution.	To place decision making in the hands of the public.
Examples of methods of engagement	News releases Fact sheets Websites Open houses Ads/flyers Info hotlines Talk shows	Websites Focus groups Surveys Public/small groups meetings	Workshops Roundtables Deliberative polling Public/small group meetings	Advisory committees Partnerships Consensus building Participatory decision making	Citizen juries Ballots Delegated decisions Service contracts

Enhanced care and improved service delivery occur when the public is effectively engaged.^{Footnote 140},^{Footnote 141} The success of patient–client engagement processes relies in a large part on the effectiveness of the health care culture in shifting from a largely hierarchical and top-down model to one where power is shared or is neutral across patient–clients and providers.^{Footnote 142} Since such a shift requires considerable energy and time to implement, success also relies on it being well-supported within the organizational structure and culture of the health care setting.

8.2 Supporting the Culture of Family-Centred Maternity and Newborn Care

A supportive organizational culture is key to transforming a system.^{Footnote 143} Establishing and supporting a new paradigm for maternity care requires the sustained application of FCMNC principles and building on any initial structural changes made to the health care system. Once areas for positive change have been identified, the following strategies will help to create and sustain cultural and organizational change:

• Aligning vision and action: Connecting the vision and the action requires structural change through all levels of an organization (resource allocation plans, budget decisions).^{Footnote 144}
• Making incremental changes: Although system and policy-driven change provides the necessary framework to support widespread changes, small and incremental shifts can accrue, leading to significant, overarching improvements.^{Footnote 145}
• Fostering distributed leadership: System- or hospital-wide change is a "wicked problem," that is, a problem characterized as having no single solution or resisting resolution due to incomplete or contradictory viewpoints.^{Footnote 146} Practically, this means that health care system change is a problem that cannot be solved in organizational isolation, but requires shared leadership and responsibility and the commitment to shared decision models to reduce organizational fragmentation.^{Footnote 147}
• Promoting staff engagement: Sharing in the decision making by involving all levels of personnel through focus groups, unit-level improvement teams, brainstorming sessions, rapid results feedback of completed small-scale projects, on-site visits, teleconferences, and individual consultations.^{Footnote 147} Although time intensive, authentic outreach underscores meaningful solutions.
• Creating and fostering collaborative interpersonal relationships: At a hospital level, mechanisms to encourage collaboration among members of the health care team with different roles and responsibilities facilitate a culture of collaboration essential to sustaining necessary structural changes. Collaborative relationships are supported in many ways, such as "through the creation of task forces, problem-specific committees or learning groups that support collaborative action, with time allocation and reward structures that encourage participation from a broad range of stakeholders."
• Paying attention to context: System changes can elicit concern and even anxiety about professional livelihood. Processes are needed to support staff and sustain engagement in iterative feedback about the consequences of change, some of which may be unintended. It is essential to ensure policies are in place to respond to workers' concerns.^{Footnote 148}

9. Evaluation of Care

The lack of consensus definitions and the organizational differences across provinces and territories have hindered pan-Canadian data analysis. While collecting national data is difficult, its dissemination and utilization can also be problematic. In particular, privacy concerns may constrain the analysis of subgroups of databases (for example, mothers requiring specialized or intensive care or NICU admissions). But such analyses are crucial towards effectively understanding the personal and clinical needs of higher-risk segments of the population. A balance needs to be achieved between privacy considerations and the effective provision of maternal and newborn care services (e.g., access to anonymous or aggregated data).

Successful implementation of FCMNC calls for an efficient, reliable and timely system that evaluates clinical care outcomes and also learns how women and their families perceive their maternity experiences.

Evaluation of care involves carefully documenting both process and outcome indicators. It also involves thoughtful review and analysis of the information within an anonymous reporting structure to ensure full disclosure in order to actualize improved care.

Evaluating maternal and newborn care is often considered the responsibility of regional and national organizations. Each unit and service provider, however, should participate in the evaluation to determine success in ensuring accessible, appropriate, and affordable care for mothers, babies, and families. Local multidisciplinary maternal and newborn committees fulfill this function. High-reliability organizations (HROs) are those that "achieve safety quality and efficiency goals by employing five central principles: (1) sensitivity to operations (i.e.,heightened awareness of the state of relevant systems and processes); (2) reluctance to simplify (i.e., the acceptance that work is complex, with the potential to fail in new and unexpected ways); (3) preoccupation with failure (i.e.,to view near misses as opportunities to improve, rather than proof of success); (4) deference to expertise (i.e.,to value insights from staff with the most pertinent safety knowledge over those with greater seniority); (5) and practicing resilience (i.e.,to prioritize emergency training for many unlikely, but possible, system failures)".^{Footnote 149}

9.1 The Importance of Continuous Quality Improvement

CQI in health care is a mechanism for thinking about the processes and outcomes of comprehensively assessed quality. A key attribute of CQI for FCMNC is the development of indicators or measures that are important to all key stakeholders—including women and families. Ensuring that these shared measures are valid and the outcomes useful for improving health care requires active engagement with women and families to learn about their experiences. CQI or evaluation frameworks can be developed on the basis of HCPs documenting these experiences of care.

Ideally, the process evolves iteratively as new data and new models of care are implemented, enabling system course correction as parts of the care pathway require adjustment. Since one size does not fit all, decision-makers will want to build flexibility into their CQI and evaluation frameworks, respecting the contextual differences between settings in terms of how FCMNC is implemented. The systematic application of site-specific, relevant, and family-informed measures leads to quality improvement processes that will guide the maturation of FCMNC in Canada.

Achieving family-centred care depends on authentically involving women and families who receive such care, and asking them to articulate what care is like and how to measure success in care. The resurgence of midwifery in Canada is an example of responding to patient–client care preferences–it attests to the fundamental tenet of informed decision-making and to the capacity of clients to create an environment that directly reflects their needs through home birth. In the hospital setting, the commitment to implementing FCMNC principles is growing, along with an openness towards this care being directed by those receiving it.

As a measure of quality of health care services, indicators can help to support improvement and accountability.^{Footnote 150},^{Footnote 151} A systematic literature review evaluating the provision of maternal and child health internationally identified 87 key indicators in categories such as preventive activities, diagnostic and/or screening tools, treatment activities, maternal mortality, maternal morbidity, child mortality, and child morbidity.^{Footnote 151} In Canada, perinatal health indicators (PHI) are grouped into four key health domains: health behaviours and practices, health services, maternal outcomes, and infant outcomes.^{Footnote 152}

The range of indicators applied both nationally and internationally underscores the contextual nature of markers of quality and safety in maternity care and emphasizes the importance of applying a nuanced approach when considering the social determinants of access to family-centred perinatal care. Furthermore, the broad range of maternal and health indicators in the literature underscores the importance of well-integrated, interprofessional collaboration including with those with expertise in mental health and diet/nutrition. This conclusion is supported by the Global Affairs Canada Evaluation of the Maternal, Newborn and Child Health Initiative (2010-11 to 2017-18). This 2019 evaluation found that there is a need for "more emphasis on an integrated, multi-sectoral approach to further address determinants of health…".^{Footnote 153}

10. Planning for Pandemics

The principles of FCMNC can help inform decision making, practice, and policies during a pandemic. Adhering to the values of FCMNC is even more important when stressors are intensified and the need to feel connected and supported increases. However, certain pandemic-related hospital protocols, such as restricted access to visitation, pose barriers to family involvement during hospitalization. To address these challenges, it is essential to clearly explain the policies and mechanisms for nonphysical communication between family members.^{Footnote 154} The Institute for Patient- and Family-Centered Care recommends describing changes to policies using patient- and family-centred language. The language of partnership–including the tone, words used, and messages provided–helps communicate the essential role family members play.

If isolation becomes essential during labour and birth, hospitals can use virtual platforms to keep families informed about the mother and baby's progress. An impediment to this is a lack of adequate Internet access or the tools or resources for videoconferencing or long-distance calling. A workaround might be to issue patient–clients with a smartphone with low-cost or free Internet or prepaid calling cards. This would also allow patient–clients and family members to access translation services virtually.^{Footnote 154} At the same time, it is important to recognize the available capacity of HCPs to implement new tools/technology and to distribute limited resources.

In the past two decades alone, jurisdictions around the globe have contended with Severe Acute Respiratory Syndrome (SARS, 2003), novel H1N1 influenza virus (H1N1, 2009), Middle East Respiratory Syndrome coronavirus (MERS-CoV, 2013), the Ebola outbreak (2014-15), and the COVID-19 pandemics.^{Footnote 155} Global ecological conditions will give rise to more pandemics.^{Footnote 156} Common to all outbreaks is a surge in cases that require coordinated public health measures to reduce the burden of morbidity and mortality and avoid overwhelming health care resources.

Pandemics have implications across all population segments, including pregnant women and families, and a coordinated approach requires evidence-based planning.^{Footnote 157},^{Footnote 158},^{Footnote 159},^{Footnote 160},^{Footnote 161} Fundamental to any response is the development of clinical service models based on containing cross-infection.^{Footnote 159},^{Footnote 160},^{Footnote 162},^{Footnote 163},^{Footnote 164},^{Footnote 165} In maternity care, this can be accomplished in existing maternity wards and through temporary auxiliary maternity units to address hospital surge capacity.

Within the context of pandemic response, the psychological needs of the birthing mother and her family take on heightened importance. Isolation measures may increase the potential for intervention in labour and separation of newborns from their mothers (providing significant challenges to establishing breastfeeding). Potential effects on patient–client and family care can be mitigated by improving the focus on family supports during birth. This includes increasing the use of and access to midwives, allowing for even more women to give birth at home, away from hospital settings where such extreme restrictions are more likely to occur. As pandemics are predicted to be increasingly common in future, planning for them now is essential.

10.1 Pop-up Maternity Units

Although there are no Canadian guidelines on the use of pop-up maternity hospitals, the Guidelines for Auxiliary Maternity Units from the USA recommend expanding midwifery units (both in and out of hospital) to mitigate potential overloads in hospital capacity. The guidelinesdescribe the scope of services that such units could offer.^{Footnote 162} The pop-up units can be efficiently constructed to meet the needs of low-risk pregnant and labouring women who remain supported by a multidisciplinary leadership team (midwifery, obstetrics, neonatology and nursing).

Patient–client inclusion criteria are as follows:^{Footnote 162}

• Gestational age limited to between 36^+0/7 and 42^+0/7 weeks;
• Singleton pregnancy;
• Cephalic presentation;
• No hypertensive disorders, even if characterized as mild or controlled;
• No maternal or fetal/neonatal conditions that would exceed the capacities of the unit;
• Identification of patient–clients prior to the onset of birth.

In case patient–clients need greater levels of care, there should be in place:^{Footnote 162}

• A pre-arranged plan for the availability of obstetrical and neonatal telephone consultation and acute care services, 24/7;
• A pre-arranged plan for the emergent and non-emergent transfer of the mother and/or her newborn, 24/7.

Refer to the Guidelines for Auxiliary Maternity Units for specific requirements of temporary maternity units.^{Footnote 162}

10.2 Considerations for Hospital-based Care

In terms of pandemic preparation, the most common challenges in maternity units tend to be high patient–client turnover, coordination of staff and supplies, ethical distribution of limited medical resources, and coordination with government agencies.^{Footnote 158},^{Footnote 164} All hospitals can plan for future pandemics and other emergencies by optimizing backup communications and their response to surge capacity, preparing for potential service degradation, and stockpiling and supply-line planning.^{Footnote 158} Other important considerations for hospital-based care include early identification of cases in the community to allow for isolation at home and appropriate triage to hospital care when necessary.^{Footnote 159} Whenever possible, hospital stays should be shortened and postpartum appointments offered by way of telemedicine ^{Footnote 158}.

Guidelines and recommendations during a pandemic are quick to change as patterns of infectious disease transmission evolve and research-based knowledge becomes available.^{Footnote 166} The public requires and deserves that new information about best practices for containment and treatment be provided as it becomes available to increase their awareness and change their behaviours and help prevent disease spread.^{Footnote 167}

10.3 Health Care Provider Considerations

It is particularly difficult for maternity care providers to prevent the spread of contagions because of their close contact with women in labour.^{Footnote 161} This may affect providers' mental wellbeing—along with the potentially increased workload despite reduced contact with patient–clients (because of shortened antenatal visits, increased use of virtual care, and reduced non-urgent consultation); shortages of personal protective equipment (PPE); and the physical discomfort of using such equipment.^{Footnote 168} HCPs may also experience increased emotional output because of their role in supporting labouring women in the absence of partners or other support people as a result of hospital restrictions. In addition, providers may feel anxious about spreading infection to their own family members and choose to self-isolate while in clinical practice. They may also be feeling the mental distress of emotionally and ethically fraught decision-making around resource allocation.^{Footnote 169}

Data from the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak and early research from the COVID-19 pandemic support the claim of increased anxiety, stress, and fear among HCPs.^{Footnote 168} No doubt, supporting providers during a pandemic is vital for sustaining a healthy workforce. Ways to reduce burnout and support providers experiencing emotional distress include:

• Having psychologists on staff to mitigate stress and reduce burnout;
• Screening for mental health problems and providing psychoeducation^{Footnote 169};
• Leveraging technology for the delivery of psychosocial supports;^{Footnote 168}
• Amending policies to facilitate healthier lifestyles (getting enough sleep, exercise and eating a healthy diet);
• Facility-level supports for decompression (for example, on-site exercise rooms and self-care stations along with opportunities for debriefing).

10.4 Patient–client Considerations

Understanding the complex ways in which pandemics shape the experience of pregnancy, birth, and the postpartum period is fundamental to providing appropriate family-centred care. Larger society-wide stresses may be easily magnified for the birthing family. The fear of contracting the virus and what that would mean for the health of the mother, baby, and family, of potential separation of family members, of the mother labouring alone or of partner's grief about missing their child's birth affect the birthing experience. Early data from the COVID-19 pandemic point to high levels of stress and anxiety causing or amplifying mental health concerns because of the fear of contracting the disease and the impact of physical isolation on birth plans and the birthing experience.^{Footnote 169},^{Footnote 170} One-on-one, continuous support during labour can mitigate the stress and its effect on the health of mothers and babies.^{Footnote 171}

Reducing time in the hospital (extending early labouring at home) and the number of support people are strategies that could be adopted in the development and planning of care in future pandemics.

Finding a new provider proximal to where the family lives to minimize potential travel-related exposure would also be a consideration.^{Footnote 172} Women and their families need to understand all the options where they can give birth, and the risks and benefits associated with each given their specific circumstances. Keeping women and families safe during a pandemic is best achieved by balancing public health protocols with quality evidence-informed care and human rights agendas that adequately consider the concerns of the birthing mother and family.^{Footnote 173}

The autonomy of birthing women is the highest ethical principal in childbirth and fundamental to actualizing FCMNC.^{Footnote 174} This includes autonomy in decisions about where to give birth and choice of provider and supports. This core principle is challenged when public health emergencies make individual choice subservient to the safety of the population. In these instances, decision making is guided by the harm principle, or "the justification for a government, or government agency, to take action to restrict the liberty of an individual or group" to protect others.^{Footnote 175} Restricting liberties, when applied to maternity and newborn care in a pandemic, may include limiting support people in the birthing room, restricting ambulation in labour to a confined area, or unintentionally depersonalizing providers due to the need for PPE. Despite the difficulty of maintaining a family-centred focus while observing public health restrictions, reinforcing the normalcy of birth is essential. This involves ongoing, transparent communication with the birthing mother and family about protocols that may seem constricting, with an emphasis on the goal of a healthy mother, baby, and family.

Conclusion

Over the past several decades, patient- and family-centred values and preferences have emerged as a guiding principle in maternity care and all health care in Canada. Organizing patient-centred care means health planners and providers can be more responsive by working in partnership with those they serve. This can be done at the individual level where birth is low risk, during acute situations where emergency protocols are in place to address an immediate clinical risk to the mother or baby, or where a larger societal risk exists, such as in a pandemic.

Such patient-centred thinking can be carried through the care pathway to mitigate the stress families in rural and remote areas may feel if they need emergency transport from their communities to a larger centre. Similarly, patient-centred care enhances the experience of Indigenous women and families by safely supporting the cultural practices of their choosing.

Patient-centred care can also be applied at the level of a facility by planning a physical environment that enhances principles of patient–client and family choice, autonomy, and respect. This can include, for example, single-room maternity care, the support of a partner's full involvement, and awareness of cultural inclusion in the surroundings. Introducing structural changes is only effective when these changes are also managed at a social level, by providing support for patient–clients, providers, and administrators when new practices are adopted.

At a psychological level, perinatal psychology as a profession could be developed to care for women and their families through normal pregnancies as well as when complications arise, and to support caregivers.

Health service planners can ensure that their institution's care delivery frameworks incorporate guidelines and protocols that reflect inclusivity and allow flexible application of FMCNC to safely meet the social and geographical needs of their patient-clients. At a society level, FCMNC requires that we foster a mindset based on partnerships between patient–clients, providers, and administrators in planning and evaluation, with evaluation using patient-identified metrics of quality care. Achieving a consensus that the right things are being measured is essential to success.

As reflected in many of the FCMNC principles outlined in the Preface and considered throughout the chapters, family-centered care requires that we consider all experiences of maternity care, including those of racialized and immigrant women and families, those who are gender non-conforming, those who have mental health concerns, and those who are disenfranchised through lack of stable housing or substance use. Their voices, and those of other vulnerable women such as those with chronic health conditions including obesity, are essential to include in service planning if we are to reduce health disparities. The principles of FCMNC may be particularly difficult to implement under extreme circumstances, but reconciling them with safe, culturally, and psychologically sensitive practices will enhance the care provided.