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

Assessing maternity care access: impacts on cesarean sections and dystocia

BACKGROUND

As South Korea grapples with a declining birthrate, maternity care accessibility has become challenging. This study examines the association with labour intervention and pregnancy complication, specifically focusing on C-section and dystocia in maternity disparities.

METHODS

Data from the South Korean NHIS-NID was used to analyze 1,437,186 women with childbirths between 2010 and 2015. The research defines 50 specific districts as Obstetrically Underserved Areas produced by the Ministry of Health and Welfare in 2011. C-Section were assessed through using medical procedure and DRG codes, while dystocia was defined using ICD-10 code. Logistic regression analysis was used to examine the significance of the association.

RESULTS

Among the population residing in underserved areas, 42,873 out of a total of 1,437,186 individuals were identified. For nationwide cases, the odds ratios (ORs) for C-Section were 1.11 (95% CI: 1.08-1.13) and dystocia were 1.07 (95% CI: 1.05-1.09). In relatively accessible urban areas, the ORs for C-Section and dystocia, based on whether they were obstetrically underserved areas, were 1.16 (95% CI: 1.13-1.18) and 1.10 (95% CI: 1.08-1.19), respectively.

CONCLUSION

Poor accessibility to maternity care facilities is closely linked to high-risk pregnancies, including an increased incidence of dystocia and a higher rate of C-sections. Insufficient access to maternity care not only raises the risk of serious pregnancy complications. Consequently, there is a pressing need for multi-faceted efforts to bridge this disparity.

The application of the ICD-10 for antepartum stillbirth patients in a referral centre of Eastern China: a retrospective study from 2015 to 2022

BACKGROUND

The causes of some stillbirths are unclear, and additional work must be done to investigate the risk factors for stillbirths.

OBJECTIVE

To apply the International Classification of Disease-10 (ICD-10) for antepartum stillbirth at a referral center in eastern China.

METHODS

Antepartum stillbirths were grouped according to the cause of death according to the International Classification of Disease-10 (ICD-10) criteria. The main maternal condition at the time of antepartum stillbirth was assigned to each patient.

RESULTS

Antepartum stillbirths were mostly classified as fetal deaths of unspecified cause, antepartum hypoxia. Although more than half of the mothers were without an identified condition at the time of the antepartum stillbirth, where there was a maternal condition associated with perinatal death, maternal medical and surgical conditions and maternal complications during pregnancy were most common. Of all the stillbirths, 51.2% occurred between 28 and 37 weeks of gestation, the main causes of stillbirth at different gestational ages also differed. Autopsy and chromosomal microarray analysis (CMA) were recommended in all stillbirths, but only 3.6% received autopsy and 10.5% underwent chromosomal microarray analysis.

CONCLUSIONS

The ICD-10 is helpful in classifying the causes of stillbirths, but more than half of the stillbirths in our study were unexplained; therefore, additional work must be done. And the ICD-10 score may need to be improved, such as by classifying stillbirths according to gestational age. Autopsy and CMA could help determine the cause of stillbirth, but the acceptance of these methods is currently low.

Driving time drives the hospital choice: choice models for pelvic organ prolapse surgery in Italy

OBJECTIVE

The Italian healthcare jurisdiction promotes patient mobility, which is a major determinant of practice variation, thus being related to the equity of access to health services. We aimed to explore how travel times, waiting times, and other efficiency- and quality-related hospital attributes influenced the hospital choice of women needing pelvic organ prolapse (POP) surgery in Tuscany, Italy.

METHODS

We obtained the study population from Hospital Discharge Records. We duplicated individual observations (n = 2533) for the number of Tuscan hospitals that provided more than 30 POP interventions from 2017 to 2019 (n = 22) and merged them with the hospitals' list. We generated the dichotomous variable "hospital choice" assuming the value one when hospitals where patients underwent surgery coincided with one of the 22 hospitals. We performed mixed logit models to explore between-hospital patient choice, gradually adding the women's features as interactions.

RESULTS

Patient choice was influenced by travel more than waiting times. A general preference for hospitals delivering higher volumes of interventions emerged. Interaction analyses showed that poorly educated women were less likely to choose distant hospitals and hospitals providing greater volumes of interventions compared to their counterpart. Women with multiple comorbidities more frequently chose hospitals with shorter average length of stay.

CONCLUSION

Travel times were the main determinants of hospital choice. Other quality- and efficiency-related hospital attributes influenced hospital choice as well. However, the effect depended on the socioeconomic and clinical background of women. Managers and policymakers should consider these findings to understand how women behave in choosing providers and thus mitigate equity gaps.

Opti'care protocol: a randomised control trial to evaluate the impact of a mobile antenatal care clinic in isolated rural areas on prenatal follow-up

INTRODUCTION

Rural residence appears to be a factor of vulnerability among pregnant women with poor clinical antenatal care. Our principal objective is to assess the impact of an infrastructure for a mobile antenatal care clinic on the completion of antenatal care for women identified as geographically vulnerable in a perinatal network.

METHODS AND ANALYSIS

Controlled cluster-randomised study in two parallel arms comparing an intervention group with an open-label control group. This study will concern the population of pregnant women who must live in one of the municipalities covered by the perinatal network and considered to be an area of geographic vulnerability. The cluster randomisation will take place according to the municipality of residence. The intervention will be the implementation of pregnancy monitoring by a mobile antenatal care clinic. The completion of antenatal care between the intervention and control groups will be a binary criterion: 1 will be attributed to each antenatal care that includes all visits and supplementary examinations. Sample size has been estimated to be 330 at least with an 80% participation rate.The univariate analyses will compare the follow-up rates (with Fisher's exact test), and all individual characteristics collected (Fisher's exact test, Student's t-test) between the two groups. The multivariate analysis will use a mixed linear model analysis and consider the cluster effect as random; the initial model will include known confounders from the literature, confounders identified in univariate analyses, and the clinically relevant prognostic factors. All of these factors will be taken into account in the model as a fixed effect.

ETHICS AND DISSEMINATION

The Patient Protection Committee North-West II approved this study on 4 February 2021 (IRB 2020-A02247-32). The results will be the subject of scientific communications and publications.

TRIAL REGISTRATION NUMBER

NCT04823104.

Social inequalities in access to care at birth and neonatal mortality: an observational study

OBJECTIVE

To look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.

DESIGN

Retrospective analysis of a prospective cohort constituted using hospital discharge databases.

SETTING

France POPULATION: Live births in 2012-2014 in maternity hospitals in mainland France followed until discharge from the hospital.

MAIN OUTCOME MEASURE

Unsuitability of the maternity to newborns' needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.

RESULTS

2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).

CONCLUSIONS

Newborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

District division administrative disaggregation data framework for monitoring leaving no one behind in the National Health Insurance Fund of Sudan: achieving sustainable development goals in 2030

BACKGROUND

The aim of this study is to monitor the concept of 'leaving no one behind' in the Sustainable Development Goals (SDGs) to track the implications of the mobilization of health care resources by the National Health Insurance Fund (NHIF) of Sudan.

METHODS

A cross-sectional study was used to monitor 'leaving no one behind' in NHIF by analyzing the secondary data of the information system for the year 2016. The study categorized the catchment areas of health care centers (HCCS) according to district administrative divisions, which are neighborhood, subdistrict, district, and zero. The District Division Administrative Disaggregation Data (DDADD) framework was developed and investigated with the use of descriptive statistics, maps of Sudan, the Mann-Whitney test, the Kruskal-Wallis test and health equity catchment indicators. SPSS ver. 18 and EndNote X8 were also used.

RESULTS

The findings show that the NHIF has mobilized HCCs according to coverage of the insured population. This mobilization protected the insured poor in high-coverage insured population districts and left those living in very low-coverage districts behind. The Mann-Whitney test presented a significant median difference in the utilization rate between catchment areas (P value < 0.001). The results showed that the utilization rate of the insured poor who accessed health care centers by neighborhood was higher than that of the insured poor who accessed by more than neighborhood in each state. The Kruskal-Wallis test of the cost of health care services per capita in each catchment area showed a difference (P value < 0.001) in the median between neighborhoods. The cost of health care services in low-coverage insured population districts was higher than that in high-coverage insured population districts.

CONCLUSION

The DDADD framework identified the inequitable distribution of health care services in low-density population districts leaves insured poor behind. Policymakers should restructure the equation of health insurance schemes based on equity and probability of illness, to distribute health care services according to needs and equity, and to remobilize resources towards districts left behind.

The impact of high intensity care around birth on long-term neurodevelopmental outcomes

BACKGROUND

An equitable and affordable healthcare system requires a constant search for the optimal way to deliver increasingly expensive neonatal care. Therefore, evaluating the impact of hospital intensity around birth on long-term health outcomes is necessary if we are to assess the value of high intensity neonatal care against its costs.

METHODS

This study exploits uneven geographical distribution of high intensity birth hospitals across Canada to generate comparisons across similar Cerebral Palsy (CP) related births treated at hospitals with different intensities. We employ a rich dataset from the Canadian Multi-Regional CP Registry (CCPR) and instrumental variables related to the mother's location of residence around birth.

RESULTS

We find that differences in hospitals' intensities are not associated with differences in clinically relevant, long-term CP health outcomes.

CONCLUSIONS

Our results suggest that existing matching mechanism of births to hospitals within large metropolitan areas could be improved by early detection of high risk births and subsequent referral of these births to high intensity birthing centers. Substantial hospitalization costs might be averted to Canadian healthcare system ($16 million with a 95% CI of $6,131,184 - $24,103,478) if CP related births were assigned to low intensity hospitals and subsequently transferred if necessary to high intensity hospitals.

Choosing where to give birth: Factors influencing migrant women's decision making in two regions of Thailand

BACKGROUND

Choosing where to give birth can be a matter of life and death for both mother and child. Migrants, registered or unregistered, may face different choices and challenges than non-migrants. Despite this, previous research on the factors migrant women consider when deciding where to give birth is very limited. This paper addresses this gap by examining women's decision making in a respective border and urban locale in Thailand.

METHODS

We held focus group discussions [13] with 72 non-Thai pregnant migrant women at non-government clinics in a rural border area and at two hospitals in Chiang Mai, a large city in Northern Thailand in 2018. We asked women where they will go to give birth and to explain the factors that influenced their decision.

RESULTS

Women identified getting the relevant documentation necessary to register their child's birth, safe birth and medical advice/quality care, as the top three factors that influenced their care seeking decision making. Language of service, free or low cost care, language of services, proximity to home, and limited alternate options for care were also identified as important considerations.

CONCLUSION

Understanding factors that migrant women value when choosing where to deliver can help health care providers to create services that are responsive to migrants' preferences and encourage provision of relevant information which may influence patient decision making. The desire to obtain birth documentation for their child appears to be important for migrants who understand the importance of personal documentation for the lives of their children. Healthcare institutions may wish to introduce processes to facilitate obtaining documentation for pregnant migrant women and their newborns.

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.

Old principles, persisting challenges: Maternal health care market alignment in Mexico in the search for UHC

The purpose of this study is to analyze the alignment of supply and demand for antenatal care (ANC) in Mexico based on the definition of access provided by Donabedian: the "degree of adjustment" between resources and needs. Alignment was studied in the teenage and adult population of Mexico that lacked conventional social security between 2008 and 2015, a period of expanding financial resources for health and public health insurance coverage. Spatial econometric methods were used to analyze data from the Ministry of Health on the supply and demand for ANC in 2,314 municipalities (94% of all municipalities in Mexico). During this period, the relative weight of ANC demand among adolescents increased 37% while the production of antenatal consultations for adolescent and adult women remained unchanged. Bivariate spatial analyses of correlation between supply and demand for ANC services yielded a minimal spatial correlation, or lack of territorial correspondence, between supply and demand among women in both age groups. Spatial econometric analysis confirmed a non-significant association between supply and demand for ANC services. Our findings suggest the existence of misalignment between supply and demand for these services. This requires a reassessment of the management and delivery of ANC services at the local level in order to increase effective coverage and improve the overall performance of the health system.

Accessibility of general and specialized obstetric care providers in Germany and England: an analysis of location and neonatal outcome

BACKGROUND

Health care accessibility is known to differ geographically. With this study we focused on analysing accessibility of general and specialized obstetric units in England and Germany with regard to urbanity, area deprivation and neonatal outcome using routine data.

METHODS

We used a floating catchment area method to measure obstetric care accessibility, the degree of urbanization (DEGURBA) to measure urbanity and the index of multiple deprivation to measure area deprivation.

RESULTS

Accessibility of general obstetric units was significantly higher in Germany compared to England (accessibility index of 16.2 vs. 11.6; p < 0.001), whereas accessibility of specialized obstetric units was higher in England (accessibility index for highest level of care of 0.235 vs. 0.002; p < 0.001). We further demonstrated higher obstetric accessibility for people living in less deprived areas in Germany (r = - 0.31; p < 0.001) whereas no correlation was present in England. There were also urban-rural disparities present, with higher accessibility in urban areas in both countries (r = 0.37-0.39; p < 0.001). The analysis did not show that accessibility affected neonatal outcomes. Finally, our computer generated model for obstetric care provider demand in terms of birth counts showed a very strong correlation with actual birth counts at obstetric units (r = 0.91-0.95; p < 0.001).

CONCLUSION

In Germany the focus of obstetric care seemed to be put on general obstetric units leading to higher accessibility compared to England. Regarding specialized obstetric care the focus in Germany was put on high level units whereas in England obstetric care seems to be more balanced between the different levels of care with larger units on average leading to higher accessibility.

Increased risk of peripartum perinatal mortality in unplanned births outside an institution: a retrospective population-based study

BACKGROUND

Births in midwife-led institutions may reduce the frequency of medical interventions and provide cost-effective care, while larger institutions offer medically and technically advanced obstetric care. Unplanned births outside an institution and intrapartum stillbirths have frequently been excluded in previous studies on adverse outcomes by place of birth.

OBJECTIVE

The objective of the study was to assess peripartum mortality by place of birth and travel time to obstetric institutions, with the hypothesis that centralization reduces institution availability but improves mortality.

STUDY DESIGN

This was a national population-based retrospective cohort study of all births in Norway from 1999 to 2009 (n = 648,555) using data from the Medical Birth Registry of Norway and Statistics Norway and including births from 22 gestational weeks or birthweight ≥500 g. Main exposures were travel time to the nearest obstetric institution and place of birth. The main clinical outcome was peripartum mortality, defined as death during birth or within 24 hours. Intrauterine fetal deaths prior to start of labor were excluded from the primary outcome.

RESULTS

A total of 1586 peripartum deaths were identified (2.5 per 1000 births). Unplanned birth outside an institution had a 3 times higher mortality (8.4 per 1000) than institutional births (2.4 per 1000), relative risk, 3.5 (95% confidence interval, 2.5-4.9) and contributed 2% (95% confidence interval, 1.2-3.0%) of the peripartum mortality at the population level. The risk of unplanned birth outside an institution increased from 0.5% to 3.3% and 4.5% with travel time <1 hour, 1-2 hours, and >2 hours, respectively. In obstetric institutions the mortality rate at term ranged from 0.7 per 1000 to 0.9 per 1000. Comparable mortality rates in different obstetric institutions indicated well-functioning routines for referral.

CONCLUSION

Unplanned birth outside an institution was associated with increased peripartum mortality and with long travel time to obstetric institutions. Structural determinants have an important impact on perinatal health in high-income countries and also for low-risk births. The results show the importance of skilled birth attendance and warrant attention from clinicians and policy makers to negative consequences of reduced access to institutions.

[Why is perinatal and infant mortality high in the Seine-Saint-Denis district? A consultation with healthcare providers using a Delphi process]

OBJECTIVE

In Seine-Saint-Denis, stillbirth and infant mortality rates are markedly higher than in other French departments. Before implementing an audit on stillbirths and neonatal deaths in 2014, we carried out a Delphi consensus process with healthcare providers to generate research hypotheses.

MATERIALS AND METHODS

A Delphi process in 3 questionnaires was conducted in 2013 with 32 healthcare providers (pediatricians, obstetricians, general practitioners, midwives, social workers, psychologists, pediatric nurses) and user representatives. The first questionnaire asked open questions about why mortality rates were higher and possible solutions to remedy the situation. In subsequent questionnaires, the panel ranked factors identified in the first questionnaires by importance.

RESULTS

One hundred and thirty factors were identified from 42 pages of text responses in the first round. From these, the 75 most highly ranked were grouped into 14 main topics organized around three themes: 1) more underlying health problems in the population, 2) access and organization of care, 3) the health consequences of poor socioeconomic conditions. Coordination of care, provider and patient communication, and access to care were highlighted.

CONCLUSION

The Delphi consensus process identified a wide range of hypotheses for the higher mortality in Seine-Saint-Denis which are adapted to the local context and based on the concerns of health practitioners.

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.

Accessibility and utilization patterns of a mobile medical clinic among vulnerable populations

We mapped mobile medical clinic (MMC) clients for spatial distribution of their self-reported locations and travel behaviors to better understand health-seeking and utilization patterns of medically vulnerable populations in Connecticut. Contrary to distance decay literature, we found that a small but significant proportion of clients was traveling substantial distances to receive repeat care at the MMC. Of 8404 total clients, 90.2% lived within 5 miles of a MMC site, yet mean utilization was highest (5.3 visits per client) among those living 11-20 miles of MMCs, primarily for those with substance use disorders. Of clients making >20 visits, 15.0% traveled >10 miles, suggesting that a significant minority of clients traveled to MMC sites because of their need-specific healthcare services, which are not only free but available at an acceptable and accommodating environment. The findings of this study contribute to the important research on healthcare utilization among vulnerable population by focusing on broader dimensions of accessibility in a setting where both mobile and fixed healthcare services coexist.

Mode of birth and social inequalities in health: the effect of maternal education and access to hospital care on cesarean delivery

Access to health care is an important factor in explaining health inequalities. This study focuses on the issue of access to health care as a driving force behind the social discrepancies in cesarean delivery using data from 707 newborn children in the 2006-2011 birth cohorts of the German Socio-Economic Panel Study (SOEP). Data on individual birth outcomes are linked to hospital data using extracts of the quality assessment reports of nearly all German hospitals. Geographic Information Systems (GIS) are used to assess hospital service clusters within a 20-km radius buffer around mother׳s homes. Logistic regression models adjusting for maternal characteristics indicate that the likelihood to deliver by a cesarean section increases for the least educated women when they face constraints with regard to access to hospital care. No differences between the education groups are observed when access to obstetric care is high, thus a high access to hospital care seems to balance out health inequalities that are related to differences in education. The results emphasize the importance of focusing on unequal access to hospital care in explaining differences in birth outcomes.

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.