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

Abstract

Background: 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. Methods: We used maternal postal codes to identify delivery records (1998-2014) of women residing in a community affected by service closure. The records were obtained from the British Columbia Perinatal Data Registry. We examined the effect of the closures using a within-communities fixed-effects framework and included similar-sized communities without service closures to control for underlying time trends. The primary outcome was a previously published composite measure of labour and delivery safety, the Adverse Outcome Index, which includes adverse events such as birth injury and unanticipated operative procedures, and includes weights for severity of adverse events. Secondary outcomes included maternal or newborn transfer, and use of obstetric interventions. Results: We found little evidence that closure of planned obstetric services affected the risk of composite adverse maternal-newborn outcome (-0.4 excess adverse events per 100 deliveries, 95% confidence interval [CI] -2.0 to 1.1), or most other secondary outcomes. The severity of composite outcome events decreased following the closures (rate ratio 0.58, 95% CI 0.36 to 0.89). Closures were associated with increases in use of epidural analgesia (3.4 excess events per 100 deliveries, 95% CI 0.4 to 6.3) and length of antepartum stay (0.6 h, 95% CI 0.1 to 1.0 h). Interpretation: Closure of planned obstetric services in low-volume hospitals was not associated with an increase or decrease in frequency of adverse events during labour and delivery.