Description of included studies—OU closures
| Author, year, country | Study design and setting | Study objectives | Study period | Eligibility criteria | Participant characteristics | Description of exposure (change over time) | Services context information | Review outcomes | |
| Perinatal | Maternal | ||||||||
| UK studies | |||||||||
| Fleming/East Lancashire study | |||||||||
| Fleming15
2013, UK (abstract) | Retrospective analysis pre and post service reconfiguration East Lancashire maternity services | To examine the effect of major service reconfiguration on CS rates | Time of reconfiguration: November 2010 Time of analysis: January-June 2010 vs January-June 2012 | NR | N: NR Characteristics: NR | Service reconfiguration Pre-change: 2 OUs Post-change: 1 OU +3 MW-led units | Universal state provision of maternity care. Approx 7000 births/yr at the new unit. | NR | CS |
| East Lancashire Hospitals NHS Trust 2017, UK (unpublished- data) | Retrospective population-based analysis of routinely collected data of service reconfiguration East Lancashire, Blackburn and Burnley | To review outcomes after centralisation of services on the Burnley general hospital site | Time of reconfiguration: November 2010 Time of analysis: 2009–2017 | NR | 2009–2017 n=53 870 births (2010 data excluded) Characteristics: NR | Amalgamation of 2 OUs Prechange: 2 OUs Postchange: 1 OU plus two birth centres | Universal state provision of maternity care. Changes driven by pressure on staff rotas, European Working Time Directive, and desire to maintain high quality service. 6000–7000 births/yr at new unit. | BBA; SB; NM | NR |
| Mackie et al
16, 2014, UK (abstract & (unpublished data) | Retrospective analysis pre- and post- service reconfiguration Pennine Acute Trust: Royal Oldham Hospital, North Manchester General Hospital and Fairfield General Hospital | To assess the effect of the amalgamation of 2 OUs to form a ‘super-centre’ with increased consultant labour ward cover | Time of OUs amalgamation 2011 Time of analysis: prechanges 2010–2011 vs postchanges 2011–2013 | NR | Preamalgamation n=5422 Postamalgamation n=5046 Characteristics: NR | Service reconfiguration Prechange: 2 OUs Postchange: 1 OU | Universal state provision of maternity care. Approx 5000 births/year at the new unit. | SB; NM; BBA | Maternal mortality; Emergency CS; third and fourth degree perineal tea; Maternal transfer to ICU |
| Other European Studies | |||||||||
| Blondel et al 5, 2011, France* | Retrospective population-based analysis of routinely collected data, OU closure Across France | To report on BBA incidence in relation to distance from OU and the closure impact on different sociodemographic groups | Time of OU closure: 2003 and 2006 Time of analysis: 2005–2006 | Included: Singleton births Excluded: Municipalities if >8% missing data, or high OOH rates. Departments excl. if >20% births already excl. | n=1 349 751 births; OOH n=5740 N Births 1349 to 751 Age (yrs) (n): <20–26 152 20–24 - 188 350 25–29 - 427 462 30–34 - 442 089 35–39 - 213 534 40+ - 52 164 Nullip (n) 774 460 SES: occupation professional (n) 217 045 intellectual 325 746 admin 266 000 retail 122 727 skilled 49 201 unskilled 84 664 none 184 368 Ethnicity, education: NR | Closure of maternity unit Pre-change: no of OUs NR Postchange: Closure of units within 15 km radius of home, number of units closed NR | Centralisation of births in larger units due to safety concerns, financial pressure, efficiency savings, and staff shortage | BBA | NR |
| Hemminki et al 18, 2011, Finland | Retrospective population-based analysis of routinely collected data, OU closure Across Finland and a specific district Uusimaa | To describe centralisation trend, unplanned out of hospital births, perinatal mortality (PM), health and birth outcomes in areas served by different levels hospitals | Time of OU closure: 1991–2008 Time of data analysis: Finland 1991–2008; Uusimaa district 2004–2008 | Inclusion: All births Exclusion: NR | 1991–2008 n=474 419 Characteristics: NR | Centralisation of births, maternity units no declined Pre-change: 49 OUs in 1991 Post-change: 34 OUs in 2008 | Universal access to maternity care, minimal private care. Pre- and postnatal care decentralised, birth hospital-based service, care of high-risk pregnancies centralised. Mean no births/hospital increased from 1339 to 1733 over study period. | BBA | NR |
| Engjom et al 7, 2014, Norway | Retrospective population-based study, 3 cohort and two cross-sectional studies, OU closure Across Norway | To assess the availability of OUs, the risk of unplanned delivery outside OU and maternal morbidity | Cohort: 1979–2009 Cross-sectional: 2000 and 2010 Time of OUs closure: 1979–2009 Time of analysis: Cohort: 1979–2009 Cross-sectional: 2000 and 2010 | Included: Age 15–49 years, known place of birth, GA ≥22 wks and/or bthwt ≥500 g Excluded: Missing maternal address, planned home birth | 1979–1983 n=252 621 2004–2009 n=409 432 Characteristics: NR | Declined in no of OUs in Norway Prechange: 95 OUs in 1979 Post-change: 51 OUs in 2009 | Universal access to maternity care; relatively dispersed population | PM | CS |
| Grytten et al 17, 2014, Norway | Retrospective population-based analysis of routinely collected data, OU closure Across Norway | To study whether neonatal and infant mortality (IM) were independent of the type of hospital in which the delivery was carried out | Time of closures: between 1979 and 2005 Time period for analysis: 5 years pre and postclosure for each hospital | Inclusion: All births Exclusion: NR | n=33 677 Characteristics: NR | Centralisation /OU closures No of local hospitals fell from 43 to 26 between 1979 and 2005. 17 maternity wards in local hospitals closed Prechange: 22 hospitals with neonatal department; 43 local hospitals; 30 maternity clinics Postchange: 22 hospitals with neonatal department; 26 local hospitals, 10 maternity clinics | Universal free access to maternity care. Low-risk births in local hospitals, high risk in central/regional hospitals. Births in central/regional hospitals increased from 65%–81% over study period. | NM; IM | NR |
| Canadian Studies | |||||||||
| Le Coutou et al 21, 1990, Canada | Retrospective population-based analysis of routinely collected data, OU closure Montreal metropolitan area | To describe the evolution of obstetric practice in Montreal metropolitan area before/ after closure of units | Time of closure: 1984–1985 Time of analysis: 1981–1985 | Inclusion: All births Exclusion: NR | 1981–1984 n=1 28 688 Characteristics: NR | 7/13 university hospitals, 5/13 specialist hospitals, 4/13 smaller units closed Prechange: 39 units in 1981 Postchange:16 | State provision of maternity care. Closures due to budgetary restrictions. | NR | Overall CS |
| Allen et al, 22 2004, Canada | Retrospective population-based analysis of routinely collected data, OU closure Eastern, Northern, Western, and Central in Nova Scotia | To evaluate the effect of hospital closures on critical obstetrical interventions and perinatal outcomes in rural communities | Preclosure: 1988–1993 Post-closure: 1996–2002 Time of analysis: 1988–1993 vs 1996–2002 | Inclusion: All births Exclusion: Delivery <20 weeks; bthwt <500 g; triplets+; major congenital anomaly | 1988–93 n=69 213 1996–2002 n=63 510 Range % Age >34 yrs: 5.6–14.8; Nullip 39.4–46.8 Twins 1.0–1.3 Ethnicity, socioeconomic status, education: NR | 1988–1993 =27 hospitals 1996–2002 =19 hospitals Reduction in maternity units from 42 to 11 between 1970 and 2002 Pre-change: 42 units in 1970 Post-change: 11 units in 2002 | State provision of maternity care. Reduction in no of units and physicians due to financial constraints and difficulty maintaining clinical competence and confidence. | SB; Foetal/neonatal mortality (NM) | NR |
| Hutcheon et al 20, 2017, Canada | Retrospective population based analysis of routinely collected data, OU closure 25 communities within British Columbia, Canada | To examine the effect of obstetric service closures on intrapartum outcomes | 1998–2014 Time of closures: between 2000 and 2012 Time of analysis: 1998–2014 | Inclusion: All births recorded in British Columbia Perinatal Data Registry (99% of deliveries) Exclusion: Communities close to larger metropolitan areas and or uncertainty about dates of service closures. | Pre-closure n=5796 Median maternal age 27 years (IQR 23–31); Nullip 39.3% Post-closure n=6153 Median maternal age 28 years (IQR 24–32); Nullip 40.7% Ethnicity, Socioeconomic status, education: NR | Centralisation /OU closures Between 1998 and 2014 one-third of hospitals stopped providing maternity services Pre-change: 21 hospitals with obstetric services Postchange: Obstetric services closed in same 21 hospitals | State provision of maternity care. Centralisation of obstetric services, majority of hospital closures in low-volume hospitals | BBA; perinatal/ NM; NNU admission | Overall CS; Maternal mortality; third/4th degree perineal tear, blood transfusion, maternal admission to ICU |
*Blondel et al 5 is also included in travel distance.
Approx, approximately; BBA, Born before arrival; bthwt, birth weight; CS, caesarean section; excl, excluded; GA, gestational age; ICU, intensive care unit; MW, midwife; NHS, National Health Services; NNU, neonatal unit; NR, not reported; Nullip, nulliparous; OU, obstetric unit; SB, stillbirth; SES, socioeconomic status; wo, without; Yr, year.