Should births be centralised in higher level hospitals? Experiences from regionalised health care in Finland

Abstract

Objective To describe: (i) trends in centralisation and unplanned out-of-hospital births; (ii) perinatal mortality by place of birth; and (iii) health and birth outcomes in areas served by hospitals of different levels.Design Cross-sectional analysis of medical birth register data. Methods In the hospital-based analysis, birthweight was adjusted by logistic regression. In the area-based analysis results were calculated according to where women lived, grouping them into areas served by different hospitals. The mother's background characteristics were adjusted for by logistic regression.Main outcome measures Place of birth, unplanned out-of-hospital birth, perinatal mortality, newborn outcomes, and birth procedures.Results The number of birthing hospitals declined, the mean number of births per hospital increased, and more births, particularly high-risk births, occurred in university hospitals. Unplanned out-of-hospital births were rare, and their numbers increased in the 2000s, but regional differences declined. Perinatal mortality was higher in the university hospitals than in other hospitals, but after adjusting for birthweight, it was lower. Among children weighing more than 2500 g, mortality was similar for all hospital levels. In out-of-hospital births, perinatal mortality was much higher than in other children. The area-based analysis did not systematically show better or worse results for the areas served by lower level hospitals: after adjusting for the background characteristics of the mothers, all differences were found to be small. ConclusionsThe health and service data do not support the need to close down small hospitals in a regionalised system where there is a referral system that functions well.

Effect of hospital size and on-call arrangements on intrapartum and early neonatal mortality among low-risk newborns in Finland

“…This negates the positive effect of centralization, since perinatal mortality rate in unplanned out-ofhospital deliveries is shown to be at least twofold compared to hospital deliveries [12]. Also, a recent Finnish study showed that by decreasing the number of delivery units from 49 to 34, the rate of unplanned out-of-hospital deliveries doubled in two decades [8]. In addition, perinatal and neonatal deaths are associated with the most expensive instances of compensation regarding patient injuries [13].…”

“…In contrast to preterm newborns, conclusions in studies on low-risk deliveries are incoherent [5]. Some studies have shown better outcomes for deliveries in tertiary hospitals [6,7] whereas others have not [8,9]. Also, current clinical practice varies among countries, thus making comparisons difficult.…”

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

“…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.…”

“…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.…”

“…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.…”