The relationship of travel distance to delivery institutions and accompa-niment for women giving birth: A systematic review - revised
Systematic review
|Published
We were commissioned to perform a systematic review of knowledge about the effect of organized follow-up and emergency preparedness services on birth outcomes in pregnant women / mothers who have a 60-90-minute, or over 90-minute journey to the maternity hospital.
Key message
Pregnant women can experience the distance between their homes and delivery institutions as unsafe for themselves and the foetus or newborn. 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/newborn who live more than 90 minutes from a delivery centre?
We searched in international databases for studies published between 2010 - 2020. We included five studies, two from Norway. From these we extracted and analysed data, assessed risk of bias and judged our confidence in the findings with appropriate tools.
For outcomes related to women in labour, results showed that a travel time of more than 60 minutes may give a small increase to the risk for Eclampsia/HELLP and may give a larger increased risk for induction for logistical reasons. Distance most likely gives a large increase in the odds of unplanned delivery outside a delivery centre. For the other outcomes, it is uncertain if a travel time of over 60 minutes is related to any change in risk of complications for pregnant women or the foetus or newborn when compared with less than 60 minutes. 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. For the other outcomes, it is uncertain if a travel time of over 60 minutes is related to any change in risk of complications for pregnant women or the foetus or newborn when compared with less than 60 minutes.
Summary
Introduction
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.
Objective
The purpose 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?
- 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 five registry based observational studies from high-income countries (Norway, Canada, and Japan). 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 850 000 participants.
For outcomes related to women in labour, the GRADE assessed results showed that a travel time of more than 60 minutes may give a small increase to the risk for Eclampsia/HELLP (adjusted RR 1.30; 95% CI 1.05-1.70) and may give a larger increased risk for induction for logistical reasons (OR 5,04; 95% CI 3.62 - 7.00). Distance most likely gives a large increase in the odds of unplanned delivery outside a delivery centre (OR 6.37; 95% CI 5.95-6.81). The evidence base is very uncertain when it comes to the risk of early delivery with pre-eclampsia. 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).
The evidence base is very uncertain in relation to the outcomes for the foetus or newborn, specifically risk for low or very low birth weight, admissions to NICU2, perinatal mortality, and premature birth (before 37 weeks). It was not possible to calculate a combined effect estimate for the outcomes of very low birth weight, perinatal mortality and premature birth. None of the studies examined the relationship of distance for APGAR score <7 after five minutes.
|
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 |
Anticipated absolute effects |
Relative effect |
Number of participants (studies) |
Certainty of the evidence (GRADE) |
||
|
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 |
5 per 1 000 |
0 less per 1 000 |
Adjusted RR 0..90 (0.70 til 1.05) |
630236 (1 observational study) |
⨁◯◯◯ VERY LOW a |
|
|
Eclampsia/ HELLP-syndrome |
2 per 1 000 |
1 more per 1 000 (0 less til 2 more) |
Adjusted RR 1.30 (1.05 til 1.70) |
630236 (1 observational study) |
⨁⨁◯◯ LOW |
|
|
Unplanned delivery outside of a delivery centre |
5 per 1 000 |
28 more per 1 000 (26 to 30 more) |
OR 6.37 (5.95 til 6.81) |
688269 (2 observational studies) |
⨁⨁⨁◯ MODERATE b |
|
|
Induction for logistical reasons |
4 per 1 000 |
14 more per 1 000 (9 to 20 more) |
OR 5.04 (3.62 til 7.00) |
49402 (1 observational study) |
⨁⨁◯◯ LOW |
|
|
Risk of distance to delivery centre for the foetus or the newborn |
||||||
|
Admission to NICU 2 |
41 per 1 000 |
6 less per 1 000 (13 less to 1 more) |
OR 0.84 (0.68 til 1.03) |
49402 (1 observational study) |
⨁◯◯◯ VERY LOW a |
|
|
CI: Confidence interval; RR: relative risk; OR odds ratio |
||||||
Explanations
- We downgraded one level for imprecision because the effect estimate showed at there was both and increased and decreased risk for the exposure group
- We upgraded one level due to a large and consistent effect estimate.
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
For outcomes related to women in labour, results showed that a travel time of more than 60 minutes may give a small increase to the risk for Eclampsia/HELLP and may give a larger increased risk for induction for logistical reasons. Distance most likely gives a large increase in the odds of unplanned delivery outside a delivery centre. For the other outcomes, it is uncertain if a travel time of over 60 minutes is related to any change in risk of complications for pregnant women or the foetus or newborn when compared with less than 60 minutes. For the other outcomes, 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 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.
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
For outcomes related to women in labour, results showed that a travel time of more than 60 minutes may give a small increase to the risk for Eclampsia/HELLP and may give a larger increased risk for induction for logistical reasons. Distance most likely gives a large increase in the odds of unplanned delivery outside a delivery centre. For the other outcomes, it is uncertain if a travel time of over 60 minutes is related to any change in risk of complications for pregnant women or the foetus or newborn when compared with less than 60 minutes. For the other outcomes, 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. There is a need for more research using standardized outcome measures.
