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  • The relationship of travel distance to delivery institutions and accompanimient for women giving birth

Systematic review

The relationship of travel distance to delivery institutions and accompanimient for women giving birth: A systematic review

Published

The objective of this systematic review is to answer the following questions: What is the relationship of distance to delivery institution for unwanted events, risk of complications and illness for the pregnant woman and the foetus/newborn? And: What is the relationship of accompaniment services compared with no accompaniment on unwanted events, risk of complications and illness for the woman and the foetus/new-born who live more than 90 minutes from a delivery centre?

Forside utøvere seksuell vold.jpg

The objective of this systematic review is to answer the following questions: What is the relationship of distance to delivery institution for unwanted events, risk of complications and illness for the pregnant woman and the foetus/newborn? And: What is the relationship of accompaniment services compared with no accompaniment on unwanted events, risk of complications and illness for the woman and the foetus/new-born who live more than 90 minutes from a delivery centre?


Downloadable as PDF. In Norwegian. English summary.

About this publication

  • Year: 2021
  • By: Norwegian Institute of Public Health
  • Authors Ames HMR, Forsetlund L, Larun L, Hval G, Muller AE.
  • ISBN (digital): 978-82-8406-185-6

Key message

Pregnant women can experience the distance between their homes and delivery institutions as unsafe for themselves and the foetus or new-born. The objective of this systematic review is to answer the following questions: What is the relationship of distance to delivery institution for unwanted events, risk of complications and illness for the pregnant woman and the foetus/new-born? And: What is the relationship of accompaniment services compared with no accompaniment on unwanted events, risk of complications and illness for the woman and the foetus/new-born who live more than 90 minutes from a delivery centre?

To identify relevant studies, we searched in international databases for studies published between 2010 - 2020. We included nine studies. From these we extracted and analysed data, appraised their methodological quality and judged our confidence in the findings with appropriate tools.

It is uncertain if a travel time of over 60 minutes is related to an increased risk of complications for pregnant women, the foetus or newborn when compared with less than 60 minutes. We assessed our certainty in the evidence as very low. There is a need for more research on this question that uses core outcome measurements. No studies investigated the relationship of accompaniment services compared with no accompaniment.

Summary

Background

Residents of rural areas often have a long way to travel to reach public services such as hospitals. Pregnant women in these areas can experience this distance as unsafe for themselves and the foetus or newborn. Weather and traffic conditions, mountain passes, and ferries can all contribute to the unpredictability of travel time.

From 2010 the regional health trusts of Norway have been responsible for continuous 24-hour emergency and accompaniment services for women in labour living far from delivery centres. A survey conducted by VG in 2019 found that 77 municipalities did not have a functioning accompaniment service. The debate about the cut-off for providing accompaniment services continues despite parliament adopting a resolution of the 4th of February 2020 to not move the cut-off time from 90 to 60 minutes.

The purpose of this systematic review is to answer the following questions:

  1. What is the relationship of distance to delivery institution for unwanted events, risk of complications and illness for the pregnant woman and the foetus/newborn?
  2. What is the relationship of accompaniment services compared with no accompaniment on unwanted events, risk of complications and illness for the woman and the foetus/newborn who live more than 90 minutes from a delivery centre?

 

Method

We conducted a systematic review following the steps described in the Norwegian Institute of Public Health’s methods handbook and in a peer-reviewed project plan. We searched for publications in seven electronic databases in December 2020. A librarian developed a search strategy which combined key and text words based on the inclusion criteria and with feedback from the research team and peer reviewers. Two researchers independently screened titles and abstracts that were 50% or more likely to be included, based on a custom machine learning classifier, and full text articles against the inclusion criteria. One researcher assessed the remaining abstracts.

We included studies from high-income countries that studied the relationship between distance to delivery centres for pregnant or labouring women and the foetus or newborn. We included serious or life-threatening complications and all possible distance measures. After a prioritization of outcomes by internal and external peer reviewers, we included seven outcomes for women and six for the foetus or newborn. Most of the included studies did not present raw data that could be combined and meta analysed. We have therefore summarised the outcomes primarily in narrative and table form.

We assessed our confidence in the evidence with the help of GRADE for results comparing a travel time of more than 60 minutes with a travel time of less than 60 mins. Results for other comparisons (reference groups of 15 mins and 15 kilometres) are presented in an appendix.

Results

We identified and included nine observational studies from high-income countries (Norway, Canada, Japan, France, Finland and the Netherlands). We focused on the comparison of more than 60 minutes and less than 60 minutes.  The studies were published between 2011-2020 and included over 6 500 000 participants.

It is uncertain if a travel time of more than 60 minutes leads to an increased risk for complications for women. With a travel time of more than 60 minutes to a delivery centre the risk for early delivery with pre-eclampsia was somewhat lower (OR 0.83; 95% CI 0.69-1.0). We have very low confidence in this result. With a travel time of more than 60 minutes to a delivery centre the risk increased for Eclampsia/HELLP (OR 1.26; 95% CI 1.01-1.59), unplanned delivery outside a delivery centre (OR 6.37; 95% CI 5.95-6.81) and induction of labour for logistic reasons (OR 5.04; CI 3.62-7.00). We have very low confidence in these results. None of the studies examined the relationship of distance to delivery centre for maternal mortality, bleeding over 500 ml, patient satisfaction, or perineal tears (3rd or 4th degree).

It is uncertain if a travel time of more than 60 minutes leads to an increased risk for complications for the foetus or newborn. With a travel time of more than 60 minutes to a delivery centre the risk for low or very low birth weight was unclear (i.e. it was not possible to calculate a combined estimate of effect), and for admissions to NICU2, the risk was somewhat lower (OR 0,83; 95% CI 0.67-1.03). We have very low confidence in these results. With a travel time of more than 60 minutes to a delivery centre the risk increased for perinatal mortality (it was again not possible to calculate a combined estimate of effect) and premature birth before 37 weeks (it was not possible to calculate a combined estimate of effect). We have very low confidence in these results. None of the studies examined the relationship of distance for APGAR score <7 after five minutes.

We found no studies that answered research question 2: What is the relationship of accompaniment services compared with no accompaniment on unwanted events, risk of complications and illness for the woman and the foetus/newborn who live more than 90 minutes from a delivery centre?

Discussion

We cannot say anything definite about the relationship of distance on the outcomes for pregnant women and foetus or new-borns based on the included studies. We can also not come to any conclusions about how these outcomes may be interconnected. The results of this systematic review are possibly generalisable to other high-income countries with rural populations far from delivery centres. They may also be transferable to other contexts where women need to travel long distance for medical help.

 

The risk of a travel time to a delivery centre of more than 60 minutes to a delivery centre compared to less than 60 minutes

Outcome

Number of participants
(studies)

Certainty of the evidence
(GRADE)

Relative

effect
(95% CI)

Anticipated absolute effects

 

Less than 60 mins travel time to the delivery centre

More than 60 mins travel time to the delivery centre

 

Risk of distance to delivery centre for women

 

Birth before 35 weeks and pre-eclampsia

630236
(1 observational study)

⨁◯◯◯
 VERY LOW b,c

OR 0.83
(0.69–1.00)

5 per 1 000

1 less per 1 000
(1 less to 0 less)

 

Eclampsia/

HELLP-syndrome

627849
(1 observational study)

⨁◯◯◯
VERY LOW b,c

OR 1.26
(1.01-1.59)

2 per 1 000

1 more per 1 000
(0 less to 1 more)

 

Unplanned delivery outside of a delivery centre

688269
(2 observational studies)

⨁◯◯◯
VERY LOW a

OR 6,37
(5,95 til 6,81)

5 per 1 000

28 more per 1 000
(26 - 30 more)

 

Induction for logistical reasons

49402
(1 observational study)

⨁◯◯◯
VERY LOW a

OR 5,04
(3,62 til 7,00)

4 per 1 000

14 more per 1 000
(9 - 20 more)

 

Risk of distance to delivery centre for the foetus or the newborn

 

 

Admission to NICU 2

49402
(1 observational study)

⨁◯◯◯
VERY LOW a,b

OR 0.84
(0.68-1.03)

41 per 1 000

6 less per 1 000
(13 less to 1 more)

 

CI: Confidence interval; OR: Odds ratio

                       

Explanation

  1. We downgraded one level for risk of bias due to unclear description of study participants and reason for distance measures; adjusted for a limited number of confounding factors.
  2. b. We downgraded one level for imprecision due to imprecise data with wide confidence intervals, some crossing zero.
  3. We downgraded one level for risk of bias due to unclear description of confounding factors and analysis

There is a need for research related to the risk with or without accompaniment services in Norway. There is also a need for standardised report with established core outcome for it to be possible to conduct a meta-analysis of the results of future studies.  We did not identify studies from high income countries that reported on the following outcomes; Maternal mortality, bleeding, perineal tears, patient satisfaction or APGAR scores <7 after five minutes.

Conclusion

It is uncertain if a travel time of more than 60 minutes has an impact on complications for pregnant or labouring women and the foetus or new-born when compared with a travel time of 60 minutes or less. There is not enough reliable research that answers this question. There is a need for more research using standardized outcome measures.