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Distance matters: a population based study examining access to maternity services for rural women Grzybowski, Stefan; Stoll, Kathrin; Kornelsen, Jude Jun 10, 2011

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RESEARCH ARTICLE Open AccessDistance matters: a population based studyexamining access to maternity services for ruralwomenStefan Grzybowski*, Kathrin Stoll and Jude KornelsenAbstractBackground: In the past fifteen years there has been a wave of closures of small maternity services in Canada andother developed nations which results in the need for rural parturient women to travel to access care. The purposeof our study is to systematically document newborn and maternal outcomes as they relate to distance to travel toaccess the nearest maternity services with Cesarean section capabililty.Methods: Study population is all women carrying a singleton pregnancy beyond 20 weeks and deliveringbetween April 1, 2000 and March 31, 2004 and residing outside of the core urban areas of British Columbia.Maternal and newborn data was linked to specific geographic catchments by the B.C. Perinatal Health Program.Catchments were stratified by distance to nearest maternity service with Cesarean section capabililty if greater than1 hour travel time or level of local service. Hierarchical logistic regression was used to test predictors of adversenewborn and maternal outcomes.Results: 49,402 cases of women and newborns resident in rural catchments were included. Adjusted odds ratiosfor perinatal mortality for newborns from catchments greater than 4 hours from services was 3.17 (95% CI 1.45-6.95). Newborns from catchments 2 to 4 hours, and 1 to 2 hours from services generated rates of 179 and 100NICU 3 days per thousand births respectively compared to 42 days for newborns from catchments served byspecialists.Conclusions: Distance matters: rural parturient women who have to travel to access maternity services haveincreased rates of adverse perinatal outcomes.BackgroundIn the past fifteen years there has been a wave of clo-sures of small rural maternity services [1-3]. This iscoincident with the regionalization of health servicesworld-wide and the concomitant challenges in recruitingand retaining rural providers [4-6]. The closure of suchservices results in the need for rural parturient womento travel to access care, [7,8] this being most challengingfor socioeconomically vulnerable women and familieswho have the most difficulty in mobilizing the financialand support resources needed to travel to access ser-vices in a referral centre [9]. Lack of local access to carein rural environments has previously been associatedwith negative perinatal outcomes [10,11]. Larimoremodelled the potential increase in perinatal mortalityassociated with the loss of maternity care providers inrural Florida and found a 9% increase was associatedwith the loss of local specialist obstetrical care [10]. Alarger population based study has shown a slightlyincreased level of risk (RR 1.4) for term newborns bornto women who live in communities served by a smallhospital (< 100 per year) compared to those in commu-nities served by a large hospital (> 2000 births) [12].While this slight but important difference supports thesupposition that it may be safer to live in or near a facil-ity providing a larger volume of maternity services itdoes not address the potential adverse outcomes asso-ciated with having no access to elective local intrapar-tum services at all. Two recent publications have found* Correspondence: sgrzybow@interchange.ubc.caCentre for Rural Health Research, Department of Family Practice, Universityof British Columbia, Vancouver, CanadaGrzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147© 2011 Grzybowski et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.an association between distance to travel to accessmaternity services and adverse outcomes [13,14].Recent evidence examining the psychological experi-ence of pregnancy in rural communities has documen-ted a 7 times greater likelihood of increased stress forwomen who have to travel more than one hour toaccess maternity services [15]. While the physiologicalmechanisms are only poorly understood, stress in preg-nancy has been associated with a range of complicationsincluding preterm labour and birth and spontaneousabortion [16-18].It is only in recent years that a systematic erosion oflong standing basic services in small rural communitieshas created the opportunity to examine the issue ofaccess in sufficient detail within the Canadian medicalcontext. The purpose of our study is to systematicallydocument newborn and maternal outcomes as theyrelate to distance to travel to access the nearest referralmaternity services.MethodsThe study setting is British Columbia, the mountainousmost western province in Canada with a population ofjust over 4.5 million scattered over just under 950,000square kms and a population density of 4.7 per squarekilometre [19,20]. Of the approximately 42,000 birthsrecorded annually we have excluded the 27,000 thatoccur to residents of the urban and suburban areas ofthe Southwestern segment of the province includingVictoria and suburbs, Vancouver and suburbs, and theadjacent Fraser Valley. The health system in BritishColumbia and across Canada provides universal medicalcoverage for core health care [21]. Access costs for resi-dents of rural and remote areas are generally theresponsibility of the individual though Aboriginal peopleliving on reserve have access to travel subsidies whenforced to leave their homes to access medical services[22,23].British Columbia has categorized Neonatal IntensiveCare units (NICU) into either Level 2 (transitioning) orLevel 3 (most severely compromised) dependant on thescope of problems (level of prematurity, respiratory sta-tus) of the newborns under care in the facility [24].There are 13 NICU’s in the province, 4 of which arelocated in rural referral centres (Prince George, Kam-loops, Kelowna, and Nanaimo).The study population is taken from the women andnewborns residing in communities ranging from smallsettlements of less than 100 people in remote valleysand coastal enclaves to residents of rural referral centreswith populations of about 100,000 such as PrinceGeorge, Kelowna and Kamloops. All women carrying asingleton pregnancy beyond 20 weeks and deliveringbetween April 1, 2000 and March 31, 2004 wereincluded in the study. As well as excluding women withtwins or multiples, we excluded all recognized congeni-tal anomalies and late terminations from the analysis inorder to more clearly focus on the relationship betweenoutcomes and services.Using data from the BC Perinatal Health Program wedefined the location of all rural maternity services in theprovince and using GIS we created geographic 1 hourtravel catchments for each maternity service [25]. InBritish Columbia rural residents’ addresses are generallydefined using a 6 digit postal code which translates intoa final postal distribution point. While specific streetaddresses exist at a community level to facilitate emer-gency access, they are not consistently recorded on birthrecords. Each postal code has a defined centroid withlongitude and latitude coordinates. We defined the dis-tance from each postal code centroid to the nearestmaternity service point and grouped all rural postalcodes into unique catchments based on proximity to amaternity service level within 60 minutes of surface tra-vel time [25]. We then extended the definition of catch-ments to women residing 1 to 2, 2 to 4, and greaterthan 4 hours from the nearest maternity service withCesarean section capability and defined the postal codesthat fell within each catchment.Maternal and newborn data was linked to specificcatchments by the B.C. Perinatal Health Program(BCPHP) using the postal code of maternal residenceregardless of the actual location of delivery. Catchmentswere stratified by distance to nearest maternity serviceor level of local service as shown in Table 1. When ahospital changed service level during the 4 years of thestudy we changed the service level designation andlinked the data with the appropriate strata.To test for significant associations among obstetricservice levels and maternal characteristics, risk factors,and perinatal outcomes, a one way Anova was per-formed for continuous variables and the chi square testfor categorical variables. P values of < 0.05 were deemedsignificant. Findings are displayed in Table 2.We performed hierarchical logistic regression analysesto examine the effect of obstetric service level on mater-nal and newborn outcomes. The newborn outcomes ofinterest were perinatal mortality (including stillbirths,and early neonatal mortality), prematurity (gestationalage < 37 weeks), and admissions to the neonatal inten-sive care unit. The maternal outcomes we examinedwere induction of labour, primary Cesarean section, andunplanned out of hospital deliveries. We controlled fortwo sets of variables: maternal characteristics and riskfactors (entered in step 1 of the logistic regressionmodel), and ecological determinants of outcomes, i.e.catchment level social vulnerability and proportion ofAboriginal people residing within the catchmentGrzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 2 of 8(entered in step 2). The primary maternal characteristicsthat were entered into all six models were maternal ageover 35 or under 16 and parity. We also controlled forthe following pre-existing or pregnancy induced medicalconditions when assessing predictors of adverse newbornoutcomes: pre-existing and/or gestational diabetes melli-tus (I and II) and antepartum hemorrhage at equal orgreater than 20 weeks gestation. Because we could detectno significant differences in the prevalence of pregnancyinduced hypertension across service levels, this medicalcondition was not included in the regression models. Forthe logistic regression model testing predictors of perina-tal mortality, a history of stillbirths and a previous neona-tal death were added as control variables. For the logisticregression model testing predictors of prematurity, his-tory of premature birth was added as a control variable.Maternity care service level was dummy coded into 5levels plus one reference category (level 6) which was thehighest level of service available in communities in ourstudy. Social vulnerability scores ranged from -1 to +1with scores closer to +1 indicating increased vulnerability[26]. The proportion of Aboriginals variable had a theo-retical range from 0-1. Analysis was done using SPSSsoftware (Version 18). Ethical approval for the study wasgranted by the University of British Columbia ethicsboard.ResultsFrom April 1, 2000 to March 31, 2004, BCPHP providedus with maternal and newborn data for 52, 139 deliveries.After exclusions there remained 49,402 cases of womenand newborns resident in the rural population catchments.Table 1 presents the distribution of women by service levelin their home communities. Over 5% of parturient womenresided in catchments with no local access to intrapartumservices within one hour travel time.Table 2 compares selected characteristics of womenacross service strata including age and parity andTable 1 Summary of obstetric service levels for Rural British Columbia (2000-2004)Obstetric Service Level Definition of Service Level # of Catchments # of Births1 No local services Greater than 240 minutes (4 Hours) from maternity services 15 5062 No local services 121-240 minutes (2-4 Hours) from maternity services 19 7473 No local services 61-120 minutes (1-2 Hours) from maternity services 23 1,3594 Primary care services with and without CesareanSection (GP Surgeons)Intrapartum care provided by Family Physicians and Midwives(No local specialist access)31 8,0315 Mixed Model C-section provided by GP surgeon or Specialist 8 5,9456 OB/GYN and General Surgery C-section provided by Obstetricians or General Surgeons 19 32,814Total 115 49,402Table 2 Maternal characteristics and ecological determinants by obstetric service level (N = 49,402)Service Level 240+ minutesfrom services120-240 minutesfrom services60-120 minutesfrom servicesPrimarycareMixedmodelSpecialist C/SServicesP-ValueMaternal characteristicsAverage maternal age 27.23 27.25 28.65 27.81 27.67 28.65 < 0.001% Nulliparous women 36.8 36.7 38.6 38.4 40.9 42.6 < 0.001Antepartum hemorrhage at or> 20 wks (%)0.8 0.8 1.9 1.1 1.2 1.0 0.037Pregnancy inducedhypertension (%)3.8 4.7 3.8 4.4 4.5 4.5 0.732Preexisting and/or gestationaldiabetes (%)2.4 3.6 3.2 3.0 2.5 4.1 < 0.001Smoking during pregnancy(%)20.6 16.5 16.5 20.3 18.0 17.9 < 0.001Alcohol use during pregnancy(%)6.5 3.2 1.5 1.3 1.7 1.6 < 0.001Ecological determinantsCatchment level socialvulnerability-1 to +1 [30]0.33 0.30 0.10 0.23 - 0.002 0.12 < 0.001Catchment proportion ofAboriginal people0.42 0.23 0.30 0.13 0.08 0.05 < 0.001Grzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 3 of 8ecological profiles such as socio-economic status andethnicity.Table 3 compares newborn outcomes across servicestrata. After adjustment for potential confounding fac-tors Table 4 demonstrates an odds ratio of 3.17 (95% CI1.45- 6.95) for perinatal mortality for births from level 1communities (> than 4 hours from intrapartumservices).Table 5 summarizes the main outcomes includingintervention rates for mothers across service strata. Fig-ure 1 demonstrates the induction rates across servicelevels and shows that rates are the highest for womentravelling 2 to 4 hours to access services. Figure 2 looksspecifically at induction for logistical reasons and showsthat this is also highest in women travelling 2 to 4hours to access services. Table 6 shows that the oddsratio for having an unplanned out of hospital birth is6.41 (95% CI 3.69, 11.28) for women 1 to 2 hours awayfrom services.Tables 4 and 6 overview the regression analyses forthe key outcomes.DiscussionThis study shows that having to travel to access intra-partum maternity services for rural parturient women isassociated with adverse outcomes for newborns andmothers and increased interventions. Even with the rela-tively small numbers of births we are able to demon-strate statistically significant increases in perinatalmortality for newborns whose mothers reside greaterthan 4 hours from services and increased rates of NICU2 admissions and numbers of NICU 2 and 3 bed daysgenerated per thousand births for newborns whosemothers reside 1-2 hours away from services. The costsof neonatal intensive care days are substantial, estimatedat $1300 day (public) for an average NICU 2 day and$2500 per day (public) for an average NICU 3 day.These system costs in adverse outcomes and actual dol-lars spent need to be considered in the planning processand it may well be that within the fiscal constraints ofthe regional planning process, the value of sustainingsmall rural hospital maternity services may be greaterthan previously appreciated. Most importantly the qual-ity of both newborn and maternal outcomes is asso-ciated with access to local services. The costeffectiveness of small rural maternity services needs tobe compared to other service situations.While system costs are important, it is also necessaryto consider the costs of travel borne by rural womenand families who may be forced to leave a rural commu-nity at 36 weeks gestational age to await the onset oflabour in a referral centre far from home [9]. Costs oftravel, accommodation, lost income for both partnersand supplemental food costs can be substantial. WhileFirst Nation and Inuit Health (FNIH) subsidizes somecosts for First Nations families who live on reserve, eventhis important contribution only goes part way to defraythe financial costs of maintaining a family out of thecommunity for several weeks. Perhaps the potentialexists for intergovernmental collaborative solutionswhich may benefit all parties.The relative distance women have to travel to accessservices also is associated with different interventionsand outcomes. Women who have to travel more than 2hours are unlikely to remain at home and try and reachthe referral hospital when they go into labour. Ourresults support previous work that has suggested thatinductions for logistical reasons are used to try andshorten the stay [27]. Women who live 1 to 2 hoursaway from services are more likely to remain at homeuntil the onset of labor particularly if they have otherchildren at home and hence are more likely to deliveren route to the hospital. This is also demonstrated inthe results and consistent with previous work [28].Table 3 Neonatal outcomes compared across obstetric service levelsService Level 240+ minutesfrom services120-240 minutesfrom services60-120 minutesfrom servicesPrimarycareMixedmodelSpecialist C/S ServicesP-Value% of deliveries at facilities with NICUbeds39.9 12.0 46.9 16.1 2.8 51.6 < 0.001Perinatal mortalityper 1000 births18 5 6 9 8 6 0.001Birth weight < 2500 grper 1000 births36 24 43 36 34 38 0.253Gestational Age < 37 weeksper 1000 births86 71 86 63 65 71 0.004NICU 2 admissions per 1000 births * 27 11 51 26 8 33 < 0.001NICU 3 admissions per 1000 births* 4 5 8 3 2 3 0.004NICU 2 days per 1000 births* 140 141 480 189 80 229 < 0.001NICU 3 days per 1000 births* 8 179 100 24 34 42 0.007*NICU 2 and 3 data only available from 2001-2004Grzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 4 of 8Table 4 Hierarchical logistic regression results for newborn outcomesPerinatal MortalityN = 49,402PrematurityN = 49,402NICU 2 AdmissionsN = 36,805OR 95% CI OR 95% CI OR 95% CIStep 1: Maternal Risk FactorsMaternal Age < 16 or > 35 1.62 (1.23, 2.14) ** 1.25 (1.14, 1.38) *** 1.22 (1.03, 1.45)*Nulliparity 1.38 (1.09, 1.72) ** 1.33 (1.24, 1.45) *** 1.40 (1.23, 1.58) ***Previous stillbirth 2.68 (1.30, 5.54) ** NA NA NA NAPrevious neonatal death 2.25 (0.81, 6.18) NA NA NA NAPrevious premature birth NA NA 4.49 (4.00, 5.03) *** NA NAAntepartum hemorrhage > 20 wks 8.29 (5.51, 12.44) *** 7.50 (6.23, 9.03) *** 5.97 (4.41, 8.10) ***Diabetes (Pre-existing and/or gestational) 0.79 (0.42, 1.49) 1.87 (1.62, 2.17) *** 3.17 (2.57, 3.91) ***Step 2: Ecological risk factorsSocial vulnerability 1.86 (1.24, 2.78) ** 1.12 (0.99, 1.27) 8.79 (6.91, 11.17) ***Proportion Aboriginal 0.73 (0.24, 2.24) 1.18 (0.79, 1.76) 0.19 (0.09, 0.39) ***Step 3: Obstetric Service LevelLevel 1 3.17 (1.45, 6.95) ** 1.11 (0.78, 1.59) 1.07 (0.54, 2.12)Level 2 0.92 (0.33, 2.53) 0.94 (0.70, 1.27) 0.31 (0.14, 0.65) ***Level 3 1.04 (0.48, 2.22) 1.12 (0.89, 1.41) 2.20 (1.59, 3.05) ***Level 4 1.44 (1.08, 1.93)* 0.85 (0.77, 0.95) ** 0.70 (0.58, 0.85) ***Level 5 1.46 (1.05, 2.03)* 0.89 (0.79, 0.99)* 0.35 (0.25, 0.50) **** P-value < .05 ** P-value < .01 *** P-value < .001NA - the variable was not included in the model as the clinical association was not felt to be strong enough to justify inclusion.Table 5 Maternal intervention rates and outcomes across obstetric service levelsService Level 240+ minutesfrom services120-240 minutesfrom services60-120 minutesfrom servicesPrimarycareMixedmodelSpecialist C/SServicesP-Value% of women who delivered atlevel 6 hospitals75.5 67.2 86.5 30.6 18.8 95.8 < 0.001% Epidural 19.8 17.3 16.6 13.6 17.8 23.7 < 0.001% Induction (excl. women withplanned CS)17.4 28.4 23.5 22.0 25.5 24.4 < 0.001% Logistics as reason forinduction2 2.1 1.5 0.7 0.2 0.3 < 0.001% Episiotomy (vag deliveriesonly)7.3 11.2 9.9 11.1 13.4 12.8 < 0.001% CS (all types) 19 20.9 23 23.7 24.8 26.2 < 0.001% Planned CS (primary andrepeat)5.5 8.0 8.2 9.3 9.6 9.8 0.006% Assisted vag. delivery 6.1 6.2 7.5 8.0 9.0 7.9 0.014% Unplanned out of hospitalbirth1.4 0.3 2.3 0.3 0.3 0.2 < 0.001Average PP length of stay(hours)51.88 55.03 53.50 53.86 59.05 57.58 < 0.001Average PP length of stay(hours) CS only92.30 84.48 83.31 78.92 86.65 84.06 < 0.001Average PP length of stay(hours) Vag delivery only41.83 47.22 44.43 45.88 49.71 48.04 < 0.001Grzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 5 of 8Limitations of the study include the necessity of usinga partial ecological design in order to include Aboriginalethnicity and socio-economic status for which data isunavailable at the case level due to privacy constraints.We have adopted an approach similar to that outlinedby Tu and Ko in their cogent review of the subject [29].NICU 2 admission rates are quite variable across thecohorts. As the clinical criteria for newborn admissionto a NICU 2 bed are less stringent than admission to aNICU 3 unit admission rates are subject to greater var-iation related to provider influence. This is demon-strated by the strong association between proportion ofa cohort born in a facility with on site access to NICUbeds and the number of newborns per thousandadmitted to a NICU 2 bed. Importantly this associationdoes not extend to admission to NICU 3 beds for whichthe criteria are much more stringent [24].Also of importance is that the results relate to a geo-graphically mountainous and coastal province on thewest coast of Canada where seasonal travel can be parti-cularly difficult due to inclement weather.The implications of this study support improvingaccess to maternity services for women from rural andremote communities. The recently published Rural BirthIndex provides a metric for systematically quantifyingneed for maternity services in rural community popula-tions and defining the appropriate service level for agiven population [30]. The Canada Health Act specifiesthat insured persons must be provided “reasonableaccess” to insured services. The research underpinningFigure 1 Induction rates compared across obstetric service levels.Figure 2 Rates of induction for logistical reasons compared across obstetric service levels.Grzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 6 of 8costs and outcomes needs to redefine what is “reason-able” because if it is reasonable then we should actaccordingly. How we treat our most vulnerable popula-tions is a measure of the strength of our society. Per-haps the evidence presented in this study contributes tothe evolving larger fabric of understanding about theimportance and effectiveness of primary care services topopulation health. If we do not provide local services torural residents we should take greater responsibility toovercome geographical barriers to access [31].ConclusionsDistance matters: rural parturient women who have totravel to access maternity services have increased ratesof adverse outcomes and newborns have increased num-bers of NICU 2 and 3 care days. Rural parturientwomen are also subject to increased rates of inductionsfor logistical reasons and unplanned out of hospitaldeliveries. Health planners and policy makers need toconsider such findings when planning the fate of ruralservices.AcknowledgementsWe would like to gratefully acknowledge funding through the CanadianInstitutes of Health Research Interdisciplinary Capacity Enhancement grant,the Provincial Health Services Association for contributing to the grant, andto the Vancouver coastal Health Research Institute for supporting the Centrefor Rural Health Research. The funding source had no involvement in any ofthe study design, collection, analysis and interpretation of data, writing ofthe report, or in the decision to submit the paper for publication. We wouldalso like to thank Jonathan Berkowitz, PhD, Statistics and Rob James, PhDEpidemiology for their helpful advice on the analysis.Authors’ contributionsSG contributed to conceptualizing the study, writing the grant proposal,implementation and data analysis, and was the lead writer of themanuscript. KS carried out the analysis and contributed to the writing of themanuscript. JK contributed to conceptualizing the study, writing the grantproposal, implementation and data analysis, and the writing of themanuscript.All authors read and approved the manuscript.Authors’ informationSG, MD, Professor and Co-Director for the Centre for Rural Health Researchin the Department of Family Practice. KS is a PhD Candidate and works withthe Centre for Rural Health Research in the Department of Family Practice atthe University of British Columbia. JK, PhD, is an Assistant Professor and Co-Director of the Centre for Rural Health Research in the Department of FamilyPractice at the University of British Columbia.Competing interestsThe authors declare that they have no competing interests.Received: 21 January 2011 Accepted: 10 June 2011Published: 10 June 2011References1. Allen VM, Jilwah N, Joseph KS, Dodds L, O’Connell CM, Luther ER, Fahey TJ,Attenborough R, Allen AC: The influence of hospital closures in NovaScotia on perinatal outcomes. J Obstet Gynaecol Can 2004, 26:1077-85.2. Hutten-Czapski P: Decline of obstetrical services in northern Ontario. CanJ Rural Med 1999, 4:72-6.3. Rourke JTB: Trends in small hospital obstetrical services in Ontario. CanFam Physician 1998, 44:2117-24.4. Rourke JT: Politics of rural health care: recruitment and retention ofphysicians. CMAJ 1993, 1488:1281-84.5. Goertzen J: The four-legged kitchen stool. Recruitment and retention ofrural family physicians. Can Fam Physician 2005, 51:1181-3.6. Brooks R, Walsh M, Mardon R, Lewis M, Clawson A: The roles of natureand nurture in the recruitment and retention of primary care physiciansin rural areas: A review of the literature. Acad Med 2002, 77:790-798.7. Chamberlain M, Barclay K: Psychosocial costs of transferring indigenouswomen from their community for birth. Midwifery 2000, 16:116-22.Table 6 Hierarchical logistic regression results for maternal outcomesPrimary Cesarean section1N = 43,122Induction of Labour2N = 44,677Out of Hospital Deliveries3N = 49,402OR 95% CI OR 95% CI OR 95% CIStep 1: Maternal Risk FactorsMaternal Age < 16 or > 35 1.72 (1.60, 1.85) *** 1.08 (1.01, 1.15) * 0.94 (0.61, 1.45)Nulliparity 5.50 (5.18, 5.83) *** 1.31 (1.26, 1.37) *** 0.30 (0.20, 0.46) ***Step 2: Ecological DeterminantsSocial vulnerability 1.09 (0.99, 1.20) 0.84 (0.78, 0.91) *** 0.49 (0.29, 0.83)**Proportion Aboriginal 1.25 (0.91, 1.71) 0.81 (0.63, 1.06) 4.79 (1.48, 15.53)**Step 3: Obstetric Service LevelLevel 1 0.67 (0.49, 0.90) ** 0.74 (0.57, 0.95) * 3.63 (1.40, 9.40) **Level 2 0.78 (0.61, 0.98) * 1.34 (1.13, 1.59) ** 0.92 (0.22, 3.88)Level 3 0.78 (0.65, 0.94) ** 1.01 (0.87, 1.17) 6.41 (3.69, 11.28) ***Level 4 0.89 (0.83, 0.96) ** 0.91 (0.86, 0.97) ** 1.40 (0.89, 2.20)Level 5 0.92 (0.85, 1.00) * 1.05 (0.98, 1.12) 0.99 (0.57, 1.73)1. Excluding women with a previous CS2. Excluding women with a planned CS3. Excluding planned home deliveries with a registered midwife* P-value < .05** P-value < .01*** P-value < .001Grzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 7 of 88. Klein MC, Christilaw J, Johnston SMB: Loss of maternity care: the cascadeof unforeseen dangers. Can J Rural Med 2002, 7:120-1.9. Kornelsen J, Grzybowski S: The Costs of Separation: The birth experiencesof women in isolated and remote communities in British Columbia.Canadian Women Studies Journal 2005, 24:75-80.10. Larimore W, Davis A: Relationship of infant mortality to availability ofcare in rural Florida. J Am Board Fam Pract 1995, 8:392-9.11. Nesbitt T, Connell F, Hart G, Rosenblatt R: Access to obstetric care in ruralareas: effect on birth outcomes. Am J Public Health 1990, 80:814-8.12. Moster D, Lie RT, Markestad T: Relation between size of delivery unit andneonatal death in low risk deliveries: population based study. Arch DisChild Fetal Neonatal Ed 1999, 80:221-5.13. Lisonkova S, Sheps SB, Janssen P, Lee SK, Dahlgren L, MacNab YC: Birthoutcomes among older mothers in rural versus urban areas: Aresidence-based approach. J Rural Health 2011, 27(2):211-19.14. Ravelli AC, de Groot MH, Erwich JJ, Rijninks-van Driel GC, Tromp M, Eskes M,Abu-Hanna A, Mol BW: Travel time from home to hospital and adverseperinatal outcomes in women at term in the Netherlands. BJOG 2011,118(4):457-65.15. Kornelsen J, Stoll K, Grzybowski S: Stress and anxiety associated with lackof access to maternity services for rural parturient women. Aust J RuralHealth 2011, 19(1):9-14.16. Heaman M, Blanchard J, Gupton A, Moffatt E, Currie F: Risk factors forspontaneous preterm birth among Aboriginal and non-Aboriginalwomen in Manitoba. Paediatr Perinat Epidemiol 2005, 19:181-93.17. Rondo P, Ferreira RF, Nogueria F, Riberio MCN, Lobert H, Artes R: Maternalpsychological stress and distress as predictors of low birth weight,prematurity and intrauterine growth retardation. Eur J Clin Nutr 2003,57:266-72.18. Sable M, Wilkinson D: Impact of perceived stress, major life events andpregnancy attitudes on low birth weight. Fam Plann Perspect 2000,32:288-94.19. Statistics Canada Table 2 Quarterly demographic estimates. StatisticsCanada; 2010 [http://www.statcan.gc.ca/daily-quotidien/100628/t100628a2-eng.htm].20. Statistics Canada Table 109-5001. Statistics Canada; 2007 [http://cansim2.statcan.gc.ca/cgi-win/cnsmcgi.exe?Lang = E&RootDir = CII/&ResultTemplate= CII/CII___&Array_Pick = 1&ArrayId = 1095001].21. Canada’s Health Care System (Medicare). Health Canada; 2010, Availablefrom: http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php.22. Non-Insured Health Benefits (NIHB) Medical Transportation PolicyFramework. Ottawa: Health Canada; 2005 [http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/_medtransp/2005_med-transp-frame-cadre/index-eng.php].23. Non-Insured Health Benefits Program-Annual Report, 2008-09, HealthCanada. Ottawa: Health Canada; 2010 [http://www.hc-sc.gc.ca/fnih-spni/pubs/nihb-ssna_e.html].24. Level of Service - Neonatal Daily Classification Tool. [http://www.perinatalservicesbc.ca/sites/bcrcp/files/psps/Neonatal_LOS_Classification.pdf].25. Schuurman N, Fiedler RS, Grzybowski S, Grund D: Defining rationalhospital catchments for non-urban areas based on travel-time. Int JHealth Geogr 2006, 3:43.26. BC Regional Socio-Economic Profiles & Indices 2009. Victoria: BC Stats;2009 [http://www.bcstats.gov.bc.ca/data/sep/i_lha/data/loverall.pdf].27. Kornelsen J, Moola S, Grzybowski S: Does distance matter? Increasedinduction rates for rural women who have to travel for intrapartumcare. J Obstet Gynaecol Can 2009, 31:21-7.28. Kornelsen J, Grzybowski S: Safety and community: The maternity careneeds of rural parturient women. J Obstet Gynaecol Can 2005, 27:554-561.29. Tu JV, Ko DT: Ecological studies and cardiovascular outcomes research.Circulation 2008, 118:2588-93.30. Grzybowski S, Kornelsen J, Schuurman N: Planning the optimal level oflocal maternity service for small rural communities: a systems study inBritish Columbia. Health Policy 2009, 92:149-57.31. Starfield B: Primary Care New York: The Oxford Press; 1998.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/147/prepubdoi:10.1186/1472-6963-11-147Cite this article as: Grzybowski et al.: Distance matters: a populationbased study examining access to maternity services for rural women.BMC Health Services Research 2011 11:147.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitGrzybowski et al. BMC Health Services Research 2011, 11:147http://www.biomedcentral.com/1472-6963/11/147Page 8 of 8


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