Availability and access in modern obstetric care: a retrospective population‐based study

Abstract

Objective To assess the availability of obstetric institutions, the risk of unplanned delivery outside an institution and maternal morbidity in a national setting in which the number of institutions declined from 95 to 51 during 30 years.Design Retrospective population-based, three cohorts and two cross-sectional analyses. Methods Geographic Information Systems software for travel zone calculations. Cross-table and multiple logistic regression analysis of change over time and regional differences. World Health Organization Emergency Obstetric and Newborn Care (EmOC) indicators.Main outcome measures Proportion of women living outside the 1-hour travel zone to obstetric institutions. Risk of unplanned delivery outside obstetric institutions. Maternal morbidity.Results The proportion of women living outside the 1-hour zone for all obstetric institutions increased from 7.9% to 8.8% from 2000 to 2010 (relative risk, 1.1; 95% confidence interval, 1.11-1.12), and for emergency obstetric care from 11.0% to 12.1% (relative risk, 1.1; 95% confidence interval, 1.09-1.11). The risk of unplanned delivery outside institutions increased from 0.4% in 1979-83 to 0.7% in 2004-09 (adjusted odds ratio, 2.0; 95% confidence interval, 1.9-2.2). Maternal morbidity increased from 1.7% in 2000 to 2.2% in 2009 (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.5) and the regional differences increased.Conclusions The availability of and access to obstetric institutions was reduced and we did not observe the expected decrease in maternal morbidity following the centralisation.

Why babies die in unplanned out‐of‐institution births: an enquiry into perinatal deaths in Norway 1999–2013

“…Thirteen were preterm breech presentations (nine between 22 and 25 gestational weeks and four between 26 and 37 weeks). Figure 1 shows a bimodal distribution of gestational age, with modes at 24 and 38 weeks and a median of 28 weeks (range [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]. Figure 2 shows the bimodal birthweight distribution, with modes at 750 and 3400 g, and the median at 905 g (range 510-4146 g).…”

“…Despite data showing higher incidence of unplanned OOI births in Norway than in other European countries, there is no evidence of a decline (1,(36)(37)(38)(39)(40)(41)(42). The national guidelines for antenatal care have no information on when and how to seek care when labor starts (43), and the Norwegian healthcare system appears to lack the ability to learn and share safety lessons about unplanned OOI births.…”

Characteristics and outcome of unplanned out‐of‐institution births in Norway from 1999 to 2013: a cross‐sectional study

“…The annual rate of unplanned births in Norway has increased from approximately 4/1000 births in 1979–1983 to 7/1000 births during the last 10 years . A study for the period 1967–1988 found a similar PMR for births during transport to hospital and other births during the last 3 years studied .…”

“…There has been a trend in many countries towards centralization of births to fewer and larger units. In Norway, the number of birth institutions went down from 158 in the year 1972 to 82 in 1990 and 57 in the year 2000 (>10 deliveries/year), and has now levelled off at 51 . The perinatal mortality rate (PMR) decreased simultaneously, from 21.9/1000 births for the years 1967–1971 to 4.9/1000 in 2011 .…”

“…The perinatal mortality rate (PMR) decreased simultaneously, from 21.9/1000 births for the years 1967–1971 to 4.9/1000 in 2011 . More centralized and specialized care has undoubtedly contributed, but a potential downside of centralization is an increased risk for unplanned out‐of‐institution births with adverse outcomes .…”