Safety of labour and delivery following closures of obstetric services in small community hospitals

Abstract

The safety of obstetric services in small, rural communities remains uncertain. Delivery at hospitals with low delivery volumes has been correlated with better, worse and comparable pregnancy outcomes compared with delivery at larger centres, [1][2][3][4][5][6][7] and studies examining the safety of delivery at rural versus urban hospitals have likewise produced conflicting results. [8][9][10][11][12] Establishing the relative safety of obstetric care in small rural hospitals is challenging. Studies comparing health outcomes according to hospital delivery volume 3-5 are influenced by underlying referral patterns in which higher rates of adverse outcomes at larger centres may reflect referrals of high-risk women. Adjustment for maternal risk factors is unlikely to completely account for case-mix differences. Comparisons made according to catchment area (in which women are classified according to their place of residence) 1,2,4,[8][9][10][11][12] prevent bias due to referral patterns, but confounding by differences in socioeconomic status and health behaviours between women living in urban and rural areas remains a concern.10 Such comparisons also have less utility for decisions about service regionalization because the policy option is not to change rural women's place of residence to an urban setting, but rather to have rural women travel to an urban setting to deliver, which may lead to increased risks, such as unintentional out-of-hospital delivery. Since 1998, nearly one-third of hospitals in British Columbia, Canada, have stopped providing planned obstetric services. The vast majority of service closures occurred in low-volume hospitals (< 150 deliveries/yr) serving smaller, rural communities. In this study, we examined whether the frequency and severity of maternal-neonatal labour and delivery health outcomes of women residing in small communities were affected by the closure of their community hospitals. Other implications of obstetric service provision in small communities (e.g., social, economic), although important, are beyond the scope of this study. In recent decades, many smaller hospitals in British Columbia, Canada, have stopped providing planned obstetric services. We examined the effect of these service closures on the labour and delivery outcomes of pregnant women living in affected communities.

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

“…Three studies were from the UK, with two reported as abstracts only 15 16 and one an unpublished data series from East Lancashire Hospitals NHS Trust, UK (East Lancashire Hospitals NHS Trust, unpublished data 2017). There appeared to be overlap between populations reported in two studies (East Lancashire Hospitals NHS Trust, unpublished data 2017) and Fleming et al 15 Three studies were from Scandinavia, 7 17 18 three from Canada [19][20][21] and one from France. 5 Seven studies compared adverse birth outcomes before and after centralisation of services, which included closure of varying numbers of OUs.…”

Using perinatal morbidity scoring tools as a primary study outcome

“…This approach was used to evaluate how the closure of planned obstetrical services in small hospitals in British Columbia, Canada, affected the labour and delivery outcomes of women residing in affected communities. 9 Ethical approval was granted by the University of British Columbia/BC Children’s and Women’s Hospital Research Ethics Board. For illustrative purposes, we simplify the analysis to a comparison of outcomes of women living in the hospital catchment areas after versus before the closure of services (excluding the control communities used to further account for underlying time trends in the original publication).…”

“…We apply the approach to data from our recent study evaluating the safety of labour and delivery following the closure of planned obstetrical services in 21 rural hospitals in British Columbia, Canada. 9 …”

Coherence in measurement and programming in maternal and newborn health: experience from the BetterBirth trial

“…However, a paradigm shift toward interconnected care is increasingly a reality in practice, driven by the idea that addressing maternal and neonatal health together is pragmatic, cost-effective, and produces better results [7], [8]. In addition, researchers are beginning to use the measurement benefits of composite outcomes with both maternal and neonatal indicators [9], [10], [11], [12]. We support the use of composite outcomes in the maternal and newborn health field, as they circumvent a contrived prioritization of one-half of the mother–infant pair and acknowledge the interconnectedness of mothers and babies at the time of childbirth.…”

“…In addition, we averaged the causal effects of the three component outcomes such that each outcome held the same statistical weight in the composite. As an alternative, assigning weights to each component is a viable solution that other maternal and neonatal composites have used [10], [11], [12]. In our analyses, maternal morbidity rates were the main driver of positive composite outcome events because this indicator had both the highest prevalence and most variance.…”