Impact of maternity unit closures on access to obstetrical care: the French experience between 1998 and 2003

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study

OBJECTIVE

To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn.

METHODS

All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI).

RESULTS

Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate.

CONCLUSIONS

Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

Factors associated with the closure of obstetric units in German hospitals and its effects on accessibility

BACKGROUND

An increase in regionalization of obstetric services is being observed worldwide. This study investigated factors associated with the closure of obstetric units in hospitals in Germany and aimed to examine the effect of obstetric unit closure on accessibility of obstetric care.

METHODS

Secondary data of all German hospital sites with an obstetrics department were analyzed for 2014 and 2019. Backward stepwise regression was performed to identify factors associated with obstetrics department closure. Subsequently, the driving times to a hospital site with an obstetrics department were mapped, and different scenarios resulting from further regionalization were modelled.

RESULTS

Of 747 hospital sites with an obstetrics department in 2014, 85 obstetrics departments closed down by 2019. The annual number of live births in a hospital site (OR = 0.995; 95% CI = 0.993-0.996), the minimal travel time between two hospital sites with an obstetrics department (OR = 0.95; 95% CI = 0.915-0.985), the availability of a pediatrics department (OR = 0.357; 95% CI = 0.126-0.863), and population density (low vs. medium OR = 0.24; 95% CI = 0.09-0.648, low vs. high OR = 0.251; 95% CI = 0.077-0.822) were observed to be factors significantly associated with the closure of obstetrics departments. Areas in which driving times to the next hospital site with an obstetrics department exceeded the 30 and 40 min threshold slightly increased from 2014 to 2019. Scenarios in which only hospital sites with a pediatrics department or hospital sites with an annual birth volume of ≥ 600 were considered resulted in large areas in which the driving times would exceed the 30 and 40 min threshold.

CONCLUSION

Close distances between hospital sites and the absence of a pediatrics department at the hospital site associate with the closure of obstetrics departments. Despite the closures, good accessibility is maintained for most areas in Germany. Although regionalization may ensure high-quality care and efficiency, further regionalization in obstetrics will have an impact on accessibility.

Consolidation of the perinatal care system and workload of obstetricians: an ecological study in Japan

Objectives

We examined the relationship between consolidation of delivery and the workload of obstetricians working at perinatal centers.

Methods

We conducted a descriptive analysis using perinatal care areas classified into three types (metropolitan, provincial, and rural). We calculated the Herfindahl-Hirschman Index (HHI) as an index of consolidation and the proportion of the deliveries at clinics as an indicator of the low-risk deliveries and the deliveries per center obstetrician as an indicator of obstetricians' workload. We used >150 deliveries yearly as an excess indicator. The correlation between the HHI and obstetricians' workload and the proportion of deliveries at clinics was examined using the Pearson correlation coefficient.

Results

The proportion of areas with  >150 deliveries yearly was higher in the consolidated areas. In provincial areas, obstetricians' workload was positively correlated with the HHI and was negatively correlated with the proportion of deliveries at clinics.

Conclusions

The obstetricians' workload may be increasing where more consolidation occurs. In provincial areas, the center obstetrician's workload could be reduced not only by consolidation but also by sharing the role of handling low-risk deliveries with clinics and hospitals with obstetric units other than perinatal centers.

Perceptions and behaviour of pregnant women in socioeconomic deprivation in rural areas. A qualitative study in France

Background

Socioeconomic deprivation (SED) is a risk factor for complications during pregnancy and childbirth, the impact of which has been studied poorly in rural areas.

Aims

To explore the perceptions and behaviour of women living in SED in a rural area with regard to their pregnancy follow‐up.

Methods

A qualitative study using semi‐structured individual interviews was carried out in a rural area in central France. To participate, the women had to have an Evaluation of Deprivation and Inequalities in Health Examination Centres deprivation score ≥ 30.17, be living in a rural area and have given birth during the month before the interview. The interviews were analysed using a thematic approach inspired by grounded theory.

Results

Seventeen women were interviewed. The difficulties of life in a rural area were linked to geographical remoteness, travel costs, lack of public services, inadequacy of nearby healthcare and social isolation. In all cases, pregnancy was an additional difficulty. The adaptive capability was related to the presence of an efficient family and social network. Most of the time, any increase in the limitations exceeded the ability to adapt and affected the medical follow‐up of the pregnancy, although follow‐up appointments were rarely abandoned altogether. Perceptions of birth preparation and parenting sessions were often limited to advice on pain management. Due to their affiliation with their rural area or their choice of lifestyle, the women complained only minimally.

Conclusion

Women often minimize any limitations and implement adaptive techniques that make identification by social and medical services more difficult.

Patient or Public Contribution

Eighteen women in SED were contacted by Childhood Medical Protection, midwives and general practitioners practising in rural areas. One woman declined participation and seventeen were interviewed.

Is limited access to obstetric services associated with adverse birth outcomes? A cross-sectional study of Korean national birth data

OBJECTIVES

The geographical disparity in the access to essential obstetric services is a public health issue in many countries. We explored the association between timely access to obstetric services and the individual risk of adverse birth outcomes.

DESIGN

Repeated cross-sectional design.

SETTING

South Korean national birth data linked with a medical service provision database.

PARTICIPANTS

1 842 718 singleton livebirths from 2014 to 2018.

PRIMARY OUTCOME MEASURES

Preterm birth (PTB), post-term birth, low birth weight (LBW) and macrosomia.

RESULTS

In the study population, 9.3% of mothers lived in districts where the Time Relevance Index (TRI) was as low as the first quartile (40.6%). Overall PTB and post-term birth rates were 5.0% and 0.1%, respectively. Among term livebirths, LBW and macrosomia occurred in 1.0% and 3.3%, respectively. When the TRI is lower, representing less access to obstetric care, the risk of macrosomia was higher (adjusted OR=1.15, 95% CI 1.11 to 1.20 for Q1 compared with Q4). Similarly, PTB is more likely to occur when TRI is lower (1.05, 95% CI 1.00 to 1.10 for Q1; 1.03, 95% CI 1.01 to 1.05 for Q2). There were some inverse associations between TRI and post-term birth (0.80, 95% CI 0.71 to 0.91, for Q2; 0.84, 95% CI 0.76 to 0.93, for Q3).

CONCLUSIONS

We observed less accessibility to obstetric service is associated with higher risks of macrosomia and PTB. This finding supports the role of obstetric service accessibility in the individual risk of adverse birth outcomes.

Out-of-maternity deliveries in France: A nationwide population-based study

Introduction

In France, many maternity hospitals have been closed as a result of hospital restructuring in an effort to reduce costs through economies of scale. These closures have naturally increased the distance between home and the closest maternity ward for women throughout the country. However, studies have shown a positive correlation between this increase in distance and the incidence of unplanned out-of-maternity deliveries (OMD). This study was conducted to estimate the frequency of OMD in France, to identify the main risk factors and to assess their impact on maternal mortality and neonatal morbidity and mortality.

Materials and methods

We conducted a population-based observational retrospective study using data from 2012 to 2014 obtained from the French hospital discharge database. We included 2,256,797 deliveries and 1,999,453 singleton newborns in mainland France, among which, 6,733 (3.0‰) were OMD. The adverse outcomes were maternal mortality in hospital or during transport, stillbirth, neonatal mortality, neonatal hospitalizations, and newborn hypothermia and polycythemia. The socio-residential environment was also included in the regression analysis. Maternal and newborn adverse outcomes associated with OMD were analyzed with Generalized Estimating Equations regressions.

Results

The distance to the nearest maternity unit was the main factor for OMD. OMD were associated with maternal death (aRR 6.5 [1.6–26.3]) and all of the neonatal adverse outcomes: stillbirth (3.3 [2.8–3.8]), neonatal death (1.9 [1.2–3.1]), neonatal hospitalization (1.2 [1.1–1.3]), newborn hypothermia (5.9 [5.2–6.6]) and newborn polycythemia (4.8 [3.5–6.4]).

Discussion

In France, OMD increased over the study period. OMD were associated with all the adverse outcomes studied for mothers and newborns. Caregivers, including emergency teams, need to be better prepared for the management these at-risk cases. Furthermore, the increase in adverse outcomes, and the additional generated costs, should be considered carefully by the relevant authorities before any decisions are made to close or merge existing maternity units.

How far is too far? A nationwide cross-sectional study for establishing optimal hospital access time for Korean pregnant women

OBJECTIVES

Access to a delivery unit is a major factor in determining maternal morbidity and mortality. However, there is little information about the optimal access time to a delivery unit. This study aimed to establish the optimal hospital access time (OHAT) for pregnant women in South Korea.

DESIGN

Nationwide cross-sectional study.

SETTING

We used the National Health Insurance System database of South Korea.

PARTICIPANTS

We analysed the data of 371 341 women who had experienced pregnancy in 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

Access time to hospital was defined as the time required to travel from the patient's home to the delivery unit. The incidence of obstetric complications was plotted against the access time to hospital. Change-point analysis was performed to identify the OHAT by determining a point wherein the incidence of obstetric complications changed significantly. As a final step, the risk of obstetric complications was compared by type among pregnant women who lived within the OHAT against those who lived outside the OHAT.

RESULTS

The OHAT associated with each adverse pregnancy outcomes were as follows: inadequate prenatal care, 41-50 min; preeclampsia, 51-60 min; placental abruption, 51-60 min; preterm delivery, 31-40 min; postpartum transfusion, 31-40 min; uterine artery embolisation, 31-40 min; admission to intensive care unit, 31-40 min; and caesarean hysterectomy, 31-40 min. Pregnant women who lived outside the OHAT had significantly higher risk for obstetric complications than those who lived within the OHAT.

CONCLUSIONS

Our results showed that the OHAT for each obstetric complication ranged between 31 and 60 min. The Korean government should take the OHAT under consideration when establishing interventions for pregnant women who live outside OHAT to reduce maternal morbidity and mortality.

Accessibility of Prenatal Care Can Affect Inequitable Health Outcomes of Pregnant Women Living in Obstetric Care Underserved Areas: a Nationwide Population-Based Study

BACKGROUND

As of 2011, among 250 administrative districts in Korea, 54 districts did not have obstetrics and gynecology clinics or hospitals providing prenatal care and delivery services. The Korean government designated 38 regions among 54 districts as "Obstetric Care Underserved Areas (OCUA)." However, little is known there are any differences in pregnancy, prenatal care, and outcomes of women dwelling in OCUA compared to women in other areas. The purposes of this study were to compare the pregnancy related indicators (PRIs) and adequacy of prenatal care between OCUA region and non-OCUA region.

METHODS

Using National Health Insurance database in Korea from January 1, 2012 to December 31, 2014, we constructed the whole dataset of women who terminated pregnancy including delivery and abortion. We assessed incidence rate of 17 PRIs and adequacy of prenatal care. All indicators were compared between OCUA group and non-OCUA group.

RESULTS

The women dwelling in OCUA regions were more likely to get abortion (4.6% in OCUA vs. 3.6% in non-OCUA) and receive inadequate prenatal care (7.2% vs. 4.4%). Regarding abortion rate, there were significant regional differences in abortion rate. The highest abortion rate was 10.3% and the lowest region was 1.2%. Among 38 OCUA regions, 29 regions' abortion rates were higher than the national average of abortion rate (3.56%) and there were 10 regions in which abortion rates were higher than 7.0%. In addition, some PRIs such as acute pyelonephritis and transfusion in obstetric hemorrhage were more worse in OCUA regions compared to non-OCUA regions.

CONCLUSION

PRIs are different according to the regions where women are living. The Korean government should make an effort reducing these gaps of obstetric cares between OCUA and non-OCUA.

Travel Time to Hospital for Childbirth: Comparing Calculated Versus Reported Travel Times in France

Objectives Timely access to health care is critical in obstetrics. Yet obtaining reliable estimates of travel times to hospital for childbirth poses methodological challenges. We compared two measures of travel time, self-reported and calculated, to assess concordance and to identify determinants of long travel time to hospital for childbirth. Methods Data came from the 2010 French National Perinatal Survey, a national representative sample of births (N = 14 681). We compared both travel time measures by maternal, maternity unit and geographic characteristics in rural, peri-urban and urban areas. Logistic regression models were used to study factors associated with reported and calculated times ≥30 min. Cohen's kappa coefficients were also calculated to estimate the agreement between reported and calculated times according to women's characteristics. Results In urban areas, the proportion of women with travel times ≥30 min was higher when reported rather than calculated times were used (11.0 vs. 3.6%). Longer reported times were associated with non-French nationality [adjusted odds ratio (aOR) 1.3 (95% CI 1.0-1.7)] and inadequate prenatal care [aOR 1.5 (95% CI 1.2-2.0)], but not for calculated times. Concordance between the two measures was higher in peri-urban and rural areas (52.4 vs. 52.3% for rural areas). Delivery in a specialised level 2 or 3 maternity unit was a principal determinant of long reported and measured times in peri-urban and rural areas. Conclusions for Practice The level of agreement between reported and calculated times varies according to geographic context. Poor measurement of travel time in urban areas may mask problems in accessibility.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States

IMPORTANCE

Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown.

OBJECTIVE

To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004.

EXPOSURES

Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.

MAIN OUTCOMES AND MEASURES

Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation).

RESULTS

Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]).

CONCLUSIONS AND RELEVANCE

In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Women's experiences with giving birth before arrival

OBJECTIVE

To explore women's experiences with giving birth before arrival.

DESIGN

A qualitative interview study.

SETTING

Individual semi structured interviews with women from Western Norway conducted in their homes in 2015.

PARTICIPANTS

10 women who experienced BBA-births in 2014, or the beginning of 2015. Two primiparous and eight multiparous women participated in the study.

KEY FINDINGS

Three themes were generated from the analysis. In the encounter with the healthcare services, the women described midwives as gatekeepers defining active labour. Giving birth before arrival was dramatic, but at some point fear of giving birth alone was replaced by feelings of coping, and in hindsight they felt empowered. The women described giving birth before arrival to be a special experience, but this was not always acknowledged by the midwives.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The findings in this study question the cost-benefit of today's maternity care system pointing towards a more differentiated and decentralised care. To enhance patient safety adequate capacity of midwives in the maternity care is essential. Furthermore, good communication skills are key to improving practice and enhancing safety. Further research must be conducted.

The effect of concentrating obstetrics services in fewer hospitals on patient access: a simulation

Background

In Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly. Obstetrics services should be concentrated in fewer hospitals to improve quality of care and reduce the workload of obstetricians. However, the impact of this intensification of services on access to obstetrics hospitals is not known. We undertook a simulation to examine how the intensification of obstetrics services would affect access to hospitals based on a variety of scenarios, and the implications for health policy.

Methods

The female population aged between 15 and 49 living within a 30-min drive of an obstetrics hospital was calculated using a Geographic Information System for three possible intensification scenarios: Scenario 1 retained facilities with a higher volume of deliveries without considering the geographic boundaries of Medical Service Areas (MSAs, zones of healthcare administration and management); Scenario 2 prioritized retaining at least one hospital in each MSA and then retained higher delivery volume institutions, while Scenario 3 retained facilities to maximize population coverage using location-allocation modeling. We also assessed the impact of concentrating services in academic hospitals and specialist perinatal medical centers (PMCs) alone.

Results

In 2011, 95.0 % of women aged 15–49 years lived within a 30-min drive of one of 1075 obstetrics hospitals. This would fall to 82.7 % if obstetrics services were intensified into academic hospitals and general and regional PMCs. If 55.0 % of institutions provided obstetrics services, the coverage would be 87.6 % in Scenario 1, whereas intensification based on access would achieve over 90.5 % coverage in Scenario 2 and 93.9 % in Scenario 3.

Conclusions

Intensification of obstetrics facilities impairs access, but a greater caseload and better staffing have the potential advantages of better clinical outcomes and reduced costs. It is essential to consult residents of hospital catchment areas when reorganizing clinical services; a simulation is a useful means of informing these important discussions.

The geography of maternal and newborn health: the state of the art

As the deadline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn health are the least likely to be achieved by 2015. It is therefore critical to ensure that all possible data, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has always represented a powerful way to ‘tell the story’ of a health problem in an easily understood way. In addition to this, the advanced analytical methods and models now being embedded into Geographic Information Systems allow a more in-depth analysis of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current state of the art in mapping the geography of MNH as a starting point to unleashing the potential of these under-used approaches. Using a rapid literature review and the description of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved decision-making. The paper is aimed at health metrics and geography of health specialists, the MNH community, as well as policy-makers in developing countries and international donor agencies.

A review of rural and remote health service indexes: are they relevant for the development of an Australian rural birth index?

BACKGROUND

Policy informs the planning and delivery of rural and remote maternity services and influences the perinatal outcomes of the 30 per cent of Australian women and their babies who live outside the major cities. Currently however, there are no planning tools that identify the optimal level of birthing services for rural and remote communities in Australia. To address this, the Australian government has prioritised the development of a rigorous methodology in the Australian National Maternity Services Plan to inform the planning of rural and remote maternity services.

METHODS

A review of the literature was undertaken to identify planning indexes with component variables as outlined in the Australian National Maternity Services Plan. The indexes were also relevant if they described need associated with a specific type and level of health service in rural and remote areas of high income countries. Only indexes that modelled a range of socioeconomic and or geographical variables, identified access or need for a specific service type in rural and remote communities were included in the review.

RESULTS

Four indexes, two Australian and two Canadian met the inclusion criteria. They used combinations of variables including: geographical placement of services; isolation from services and socioeconomic vulnerability to identify access to a type and level of health service in rural and remote areas within 60 minutes. Where geographic isolation reduces access to services for high needs populations, additional measures of disadvantage including indigeneity could strengthen vulnerability scores.

CONCLUSION

Current planning indexes are applicable for the development of an Australian rural birthing index. The variables in each of the indexes were relevant, however use of flexible sized catchments to accurately account for population births and weighting for extreme geographic isolation needs to be considered. Additionally, socioeconomic variables are required that will reflect need for services particularly for isolated high needs populations. These variables could be used with Australian data and appropriate cut-off points to confirm applicability for maternity services. All of the indexes used similar types of variables and are relevant for the development of an Australian Rural Birth Index.

Lessons for providers and hospitals from Philadelphia's obstetric services closures and consolidations, 1997-2012

The Affordable Care Act is triggering an increase in hospital consolidation and mergers. How other hospitals respond to these disruptions in supply could influence patient outcomes. We examined the experience of Philadelphia County, Pennsylvania (coterminous with the city of Philadelphia), where thirteen of nineteen hospital obstetric units closed between 1997 and 2012. Between October 2011 and January 2012 we interviewed twenty-three key informants from eleven hospitals (six urban and five suburban) whose obstetric units remained open, to understand how the large number of closures affected their operations. Informants reported having confronted numerous challenges as a result of the obstetric unit closures, including sharp surges in delivery volume and an increase in the proportion of patients with public insurance or no insurance. Informants reported adopting a number of strategies, such as innovative staffing models, to cope with the added demand brought about by the closure of nearby obstetric units. Informants emphasized that interhospital communication could mitigate closures' stresses on the health care system. Our study supports the need for policy makers to anticipate reductions in supply and monitor patient outcomes.

Concentration of gynaecology and obstetrics in Germany: is comprehensive access at stake?

Financial soundness will become more and more difficult in the future for all types of hospitals. This is particularly relevant for gynaecology and obstetrics departments: while some disciplines can expect higher demand due to demographic changes and progress in medicine and medical technology, the inpatient sector for gynaecology and obstetrics is likely to lose patients in line with these trends. In this paper we estimate future demand for gynaecology and obstetrics in Germany and develop a cost model to calculate the average profitability in this discipline. The number of inpatient cases in gynaecology and obstetrics can be expected to decrease by 3.62% between 2007 and 2020 due to the demographic change and a potential shift from inpatient to outpatient services. Small departments within the fields of gynaecology and obstetrics are already incurring heavy losses, and the anticipated decline in cases should increase this financial distress even more. As such, the further centralisation of services is indicated. We calculate travel times for gynaecology and obstetrics patients and estimate the anticipated changes in travel times by simulating different scenarios for this centralisation process. Our results show that the centralisation of hospital services in gynaecology and obstetrics may be possible without compromising comprehensive access as measured by travel times.

Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France

Background: The number of maternity units has declined in France, raising concerns about the possible impact of increasing travel distances on perinatal health outcomes. We investigated impact of distance to closest maternity unit on perinatal mortality. Methods: Data from the French National Vital Statistics Registry were used to construct foetal and neonatal mortality rates over 2001–08 by distance from mother’s municipality of residence and the closest municipality with a maternity unit. Data from French neonatal mortality certificates were used to compute neonatal death rates after out-of-hospital birth. Relative risks by distance were estimated, adjusting for individual and municipal-level characteristics. Results: Seven percent of births occurred to women residing at ≥30 km from a maternity unit and 1% at ≥45 km. Foetal and neonatal mortality rates were highest for women living at <5 km from a maternity unit. For foetal mortality, rates increased at ≥45 km compared with 5–45 km. In adjusted models, long distance to a maternity unit had no impact on overall mortality but women living closer to a maternity unit had a higher risk of neonatal mortality. Neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances. At the municipal-level, higher percentages of unemployment and foreign-born residents were associated with increased mortality. Conclusion: Overall mortality was not associated with living far from a maternity unit. Mortality was elevated in municipalities with social risk factors and located closest to a maternity unit, reflecting the location of maternity units in deprived areas with risk factors for poor outcome.

Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

The impact of obstetric unit closures on maternal and infant pregnancy outcomes

OBJECTIVE

To define the association between large-scale obstetric unit closures and relative changes in maternal and neonatal outcomes.

DATA SOURCES/STUDY SETTING

Birth and death certificates were linked to maternal and neonatal hospital discharge records for all births between January 1, 1995 and June 30, 2005 in Philadelphia, which experienced the closure of 9 of 19 obstetric units between 1997 and 2005, and five surrounding counties and eight urban counties that did not experience a similar reduction in obstetric units.

DESIGN

A before-and-after study design with an untreated control group compared changes in perinatal outcomes in Philadelphia to five surrounding control counties and eight urban control counties after controlling for case mix differences and secular trends (N = 3,140,782).

RESULTS

Relative to the preclosure years, the difference in neonatal mortality (odds ratio (OR) 1.49, 95 percent CI 1.12-2.00) and all perinatal mortality (OR 1.53, 95 percent CI 1.14-2.04) increased for Philadelphia residents compared with both control groups between 1997 and 1999. After 2000, there was no statistically significant change in any outcome in Philadelphia county compared with the preclosure epoch.

CONCLUSIONS

Obstetric unit closures were initially associated with adverse changes in perinatal outcomes, but these outcomes ameliorated over time.

Choice in maternity care: associations with unit supply, geographic accessibility and user characteristics

Background

Despite national policies to promote user choice for health services in many European countries, current trends in maternity unit closures create a context in which user choice may be reduced, not expanded. Little attention has been paid to the potential impact of closures on pregnant women’s choice of maternity unit. We study here how pregnant women’s choices interact with the distance they must travel to give birth, individual socioeconomic characteristics and the supply of maternity units in France in 2003.

Results

Overall, about one-third of women chose their maternity units based on proximity. This proportion increased steeply as supply was constrained. Greater distances between the first and second closest maternity unit were strongly associated with increasing preferences for proximity; when these distances were ≥ 30 km, over 85% of women selected the closest unit (revealed preference) and over 70% reported that proximity was the reason for their choice (expressed preference). Women living at a short distance to the closest maternity unit appeared to be more sensitive to increases in distance between their first and second closest available maternity units. The preference for proximity, expressed and revealed, was related to demographic and social characteristics: women from households in the manual worker class chose a maternity unit based on its proximity more often and also went to the nearest unit when compared with women from professional and managerial households. These sociodemographic associations held true after adjusting for supply factors, maternal age and socioeconomic status.

Conclusions

Choice seems to be arbitrated in both absolute and relative terms. Taking changes in supply into consideration and how these affect choice is an important element for assessing the real impact of maternity unit closures on pregnant women’s experiences. An indicator measuring the proportion of women for whom the distance between the first and second maternity unit is greater than 30 km can provide a simple measure of choice to complement indicators of geographic accessibility in evaluations of the impact of maternity unit closures.

Une géographie de l’offre de soins en restructuration : les territoires des maternités en Bourgogne

En France, l’organisation des services de santé périnatale subit actuellement de profondes mutations en raison de la restructuration de l’offre de soins et notamment en raison de la fermeture des petites ou moyennes maternités. Au-delà des polémiques suscitées lors de la suppression d’un établissement, ces restructurations ont-elles des répercussions sur l’accessibilité aux maternités pour les parturientes ? À la suite des fermetures successives de maternités, notre étude a pour objectif de présenter les recompositions des pratiques spatiales des femmes et de lire les nouvelles aires d’attraction. Le territoire d’étude est la région Bourgogne, territoire hétérogène, aux forces centrifuges associant des zones urbaines, périurbaines et rurales enclavées. Cette étude met en évidence les inégalités spatiales d’accès aux soins et apporte des éléments d’analyse face aux questions d’équité que se posent les décideurs et les professionnels de santé publique.

Out-of-hospital births and the supply of maternity units in France

Maternity unit closures in France have increased distances that women travel to deliver in hospital. We studied how the supply of maternity units influences the rate of out-of-hospital births using birth certificate data. In 2005-6, 4.3 per 1000 births were out-of-hospital. Rates were more than double for women living 30km or more from their nearest unit and were even higher for women of high parity. These associations persisted in multilevel analyses adjusting for other maternal characteristics. Long distances to maternity units should be a concern to health planners because of the maternal and infant health risks.

[The eastern Paris perinatal network (2008-2010). Defining the target population and assessing health needs]

BACKGROUND

Since the 1990s, governmental plans in France have imposed the regionalization of perinatal care to improve both safety and quality of care. The Eastern Paris Perinatal Network is under construction in health area 75-2, which includes the 11th, 12th, 13th and 20th arrondissements of Paris. A major issue is ensuring that the network can meet the needs of its target population. The objective is to define the network's target population of mothers and newborns.

METHODS

We designed a matrix to help assess these needs and identify the data required to define the network's population. Four principal data sources were analyzed: the National Statistics and Economic Studies Institute (Insee) data, annual health facility activity data, national medical informatics program data, and 8th-day health certificates.

RESULTS

The network's target population varies according to the precise perinatal period and the planning stage. For the conception period, it includes the general population and specifically all women of childbearing age (15-49 years). The health area included 672,000 inhabitants in 2006, 29% of them are women of childbearing age. The proportion of people born outside France and who are of foreign nationality ranges, according to arrondissement, from 13.2 to 20.0%; the mean for the Paris metropolitan area is 14.7%. Approximately 16,500 women gave birth in 2007, at nine obstetric facility sites in the health area (five level I, three level II, and one type III); only 41.46% of them resided in the health area. Approximately 2500 women living in the health area gave birth at a facility outside the area. The population likely to be covered by the network is thus estimated at approximately 19,000 women.

CONCLUSION

A network must simultaneously take into account the local resident population and the population using its health care system. In an urban area such as Paris, where the health care supply is dense, it is essential for policy planning process to define the contours of the target population of a health network.