This joint position paper has been prepared by the Joint Position Paper Working Group and approved by the Councils Executives of the Canadian Association of Midwives, the Canadian Association of Perinatal and Women's Health Nurses, the College of Family Physicians of Canada, the Society of Obstetricians and Gynaecologists of Canada and the Society of Rural Physicians of Canada.# site?
and/or ~u t t i n g.~ closures,4 large Defining "rural" in Canada remains challenging. Rurality indices attempt to capture the essence of rural with variables such as the distance between the site and advanced care, between the site and basic care, as well as the population number and density of the This definition attempts to cover the variety of rural centres from those that are geographically isolated to centres that, while close to basic and advanced care, are in regions with low population density.
Rural maternity care is often characterized by maternity care teams led by family physicians, nurses, and midwives. In some communities, they are the only ones providing maternity care, and in other cases backup is provided by general surgeons, GP-anaesthetists, obstetriciangynaecologists, family physicians with surgical training.
Recent years have seen the closure of rural maternity programs as part of regionalization

# Levels of Service
T h e safety of rural maternity services has been the subject of a number of studies over the past 20 years, and the weight of evidence supports the provision of local services even in communities without access to local surgical Several recent studies have examined the importance of distance to services as it relates to outcomes and have shown that perinatal mortality, morbidity, and intervention rates increase the farther women live from birthing While low-volume units face unique challenges, there is no evidence that a minimum number of deliveries is required to maintain competence? T h e question is not whether to provide birthing services or not but what level of services is feasible and sustainable.
When a community is unable to sustain local services, almost all women will travel to access services elsewhere and, depending on the distance to the nearest referral centre, may be away from their homes and community from 36 weeks' gestation until
give birth. This separation can cause substantial degrees of stress for women and their families, and when socioeconomic vulnerabilit y is a complicating factor, rates of adverse outcomes
Other rural communities are able to provide medically supported maternity services. If surgical services are unavailable, the proportion of women delivering locally is lower because of both risk-management decisions and patient choice. Factors that influence patient choice are not those that motivate their care Rural maternity care providers have identified many challenges including determining and accepting risk, obtaining and maintaining competencies in low-volume environments, and balancing women's needs against the realities of rural Evolving models of non-hospital-based maternity care will likely share similar challenges.
In communities with a surgical service the needs of women are more effectively met locally. In these communities, the majority (> 75%depending on provider model) of women give birth locally and the outcomes are Models such as the Rural Birth Index have been developed to aid hospitals and health care planners to measure and quantify the need for and feasibility of local maternity This model was developed and works well in British Columbia and identifies both catchment populations that are underserved and Although in areas of extremely low population density it is unrealistic to believe that all women can deliver in their home communities, it is important that Aboriginal, rural, and remote women can access low-risk maternity care that reflects their experiences, expectations, and
T h e importance of returning birth to the North and to Aboriginal communities has been acknowledged several national
In the past decade, many medical communities have responded to the declining number of care providers by creating collaborative practice models. The most common model is a group of surgeons who provide only Caesarean sections or broader surgical services. T h e evidence ph y sicians working in a shared prenatal clinic with a defined period of on-call Both physicians and patients report a high level of satisfaction with these and outcomes are At least one community notes that group practice has led to the creation of a more supportive environment and the development of best practice Communities that are unable to support sustainable surgical or obstetrical specialist care but that are large enough to justify local surgical services can effectivel y be supported suggests that they make a significant contribution to equitable access to care for rural It is essential that all rural women have access to supports such as prenatal educational, postpartum care, and lactation support even when local intrapartum services are not offered.
While differences in scope and remuneration models create barriers to true collaboration between different care provider groups, many communities have found ways to overcome them.