Impact of obstetric unit closures, travel time and distance to obstetric services on maternal and neonatal outcomes in high-income countries: a systematic review

Abstract

ObjectivesTo systematically review (1) The effect of obstetric unit (OU) closures on maternal and neonatal outcomes and (2) The association between travel distance/time to an OU and maternal and neonatal outcomes.DesignSystematic review of any quantitative studies with a comparison group.Data sourcesEmbase, MEDLINE, PsycINFO, Applied Social Science Index and Abstracts, Cumulative Index to Nursing and Allied Health and grey literature were searched.MethodsEligible studies explored the impact of closure of an OU or the effect of travel distance/time on prespecified maternal or neonatal outcomes. Only studies of women giving birth in high-income countries with universal health coverage of maternity services comparable to the UK were included. Identification of studies, extraction of data and risk of bias assessment were undertaken by at least two reviewers independently. The risk of bias checklist was based on the Cochrane Effective Practice and Organisation of Care criteria and the Newcastle-Ottawa scale. Heterogeneity across studies precluded meta-analysis and synthesis was narrative, with key findings tabulated.Results31 studies met the inclusion criteria. There was some evidence to suggest an increase in babies born before arrival following OU closures and/or associated with longer travel distances or time. This may be associated with an increased risk of perinatal or neonatal mortality, but this finding was not consistent across studies. Evidence on other maternal and neonatal outcomes was limited but did not suggest worse outcomes after closures or with longer travel times/distances. Interpretation of findings for some studies was hampered by concerns around how accurately exposures were measured, and/or a lack of adjustment for confounders or temporal changes.ConclusionIt is not possible to conclude from this review whether OU closure, increased travel distances or times are associated with worse outcomes for the mother or the baby.PROSPERO registration numberCRD42017078503.

Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study

“…The degree of such underestimation is expected to be larger in the rural compared with urban areas, as the average distance between homes and PHUs is usually longer. Therefore, our estimate of the proportion of missions within the 2-hour target should be considered conservative and not completely comparable with those from studies using other methods, including total time from home 33. On the other hand, according to the 2016 annual report or Maternal Death, Surveillance and Response,42 before NEMS inception, when patients could reach hospital facilities either through private vehicles or paying public transport, the high number of maternal deaths reported at the hospitals’ level were associated with late referral from the PHUs.…”

“…Our study shows a clear association between PT and risk of maternal and perinatal death during obstetric emergencies. While the association between PT and perinatal mortality is well studied in high-income countries, [31][32][33] only few studies evaluated the relationship between longer TT and adverse perinatal outcomes in low-income and low-middleincome countries, [34][35][36] and quantitative data on maternal risk of death are even less investigated. The high rates of perinatal deaths reported in our study concur with the results of van Duinen et al, 34 who reported a 19% perinatal mortality following emergency caesarian sections in Sierra Leone.…”

“…Therefore, our estimate of the proportion of missions within the 2-hour target should be considered conservative and not completely comparable with those from studies using other methods, including total time from home. 33 On the other hand, according to the 2016 annual report or Maternal Death, Surveillance and Response, 42 before NEMS inception, when patients could reach hospital facilities either through private vehicles or paying public transport, the high number of maternal deaths reported at the hospitals' level were associated with late referral from the PHUs. Therefore, while not providing a comprehensive evaluation of the 'second delay', we believe that in this context the estimate of the time elapsed from the first clinical assessment at the PHU to the arrival at the hospital constitutes an objective, reliable and useful indicator of the performance of the newly developed prehospital health system, highlighting existing gaps and area fur further improvements.…”

Economies of scale and optimal size of maternity services in Belgium: A Data Envelopment Analysis

“…However, rationalisation efforts of maternity services abroad also tried to balance efficiency and accessibility goals. 4,5,17 Hence it should be avoided that due to the closure of inefficient maternity services, travel time or travel distance becomes too long. Accessibility is assured in the Belgian context.…”

Centralisation of acute obstetric care in the Netherlands: a qualitative study to explore the experiences of stakeholders with adaptations in organisation of care

“…Finally, the centralisation of AOC might reduce choice in place of birth, a choice considered valuable by women [ 18 – 20 ]. Considering all the evidence, there is no clear-cut answer to whether centralisation of AOC is supported or not by the scientific literature, especially since there are differences in the extent of centralisation [ 21 ].…”