Does Distance to the Hospital Matter for Pregnant Women? Part 2

Just sharing Part two to the BIRTH SENSE article: Does Distance to the Hospital Matter for Pregnant Women?


Does Distance to the Hospital Matter for Pregnant Women? Part 2

Posted: 27 Feb 2011 07:44 AM PST

In the British Journal of Obstetrics and Gynecology article entitled Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands, authors concluded that women who must travel more than 20 minutes to the hospital while in labor experienced a greater risk of serious complications or even death to themselves and/or their babies.  They further concluded that this might have implications for women having home births but living further than 20 minutes from the hospital.

Before applying these findings to women having home births in the United States, there are some points from the study we need to consider:

  1. The Dutch maternity system is very different from ours.  As explained in the study, women are seen early in pregnancy by a midwife, and are categorized as “low” or “high” risk.  Most women fall into the low risk category, and they will either give birth at home (about 30%) or in outpatient maternity clinics.  High risk women will travel to regional hospitals, which may be a further distance to reach than maternity clinics.
  2. Within the maternity clinic (which sounds similar to our freestanding birth centers) or Dutch hospital, the system is also geared toward viewing birth as a natural event, not to be interfered with unless necessary.  Only about 10% of Dutch women use pain relief during labor, because the prevailing view is that it should not be needed in a normal, physiological labor, unless there are extenuating circumstances causing excessive pain.  Women are left alone more in labor than they are in US hospitals, and although the midwives and medical staff are vigilant to watch for signs that intervention is needed, they do not do repeated vaginal exams, continuous monitoring, etc, on a routine basis.  This is a very important point, as many women will labor more effectively with less interruption by medical staff.
  3. The authors concluded that the risk associated with travel time could be correlated with the risk status of the woman.  For instance, high-risk women were more likely to be traveling to a larger, tertiary care hospital, which would entail a longer drive for most.  Since high risk women would already be more likely to experience complications of labor and birth, it is difficult to assess whether the longer drive caused problems or the womens’  health problems caused increased risk, or both.
  4. The authors admit that other studies have not shown that increased travel time led to increased risks.
  5. The authors speculate that traveling to a larger, more distant hospital for care might pose more risk to a woman than receiving care at home or in a smaller, closer hospital. 
  6. The authors found that “low risk women at the start of labor and delivering in an outpatient clinic under primary care [care by midwives] had the lowest mortality rates, and in this group no effect of travel time is observed.
  7. The highest risks were noted for women who changed risk status during labor and had a travel time of greater than 20 minutes to the nearest care facility.

What parallels can we make to birth in the United States?  Here we have a system that does not view birth as normal, and nearly every woman giving birth in a US hospital will be treated as an imminent disaster, in stark contrast to the Dutch system.  In the Netherlands, birth is considered optimally supported with the least amount of necessary interventions.  A woman who must travel farther than 20 minutes to a US hospital is also taking increased risks upon herself by being admitted in early labor, because the odds are great that staff routines will interfere with the normal progress of her labor, setting off a cascade of interventions.  So what common-sense steps could the US maternity system take to apply the findings of this study to obstetrics?

  1. Increase support for home birth, including group meetings of midwives and obstetricians, to develop a system of seamless consultation, collaboration, and referral when needed.
  2. Increase the availability of birth centers near to hospitals, with midwives collaborating to offer home or birth center births, depending on a woman’s risk status and distance from hospital.
  3. While a hotel near the hospital is always an option (and I’ve delivered some babies in hotels myself), why couldn’t hospitals build “maternity homes” adjacent to their facilities?  If a woman wanted a hospital birth, but had some distance to travel, this would be a hotel-like facility where women and their families could sleep, eat, walk, sit in a jacuzzi, and relax in an attractive, quiet environment, until labor was well-established.  A nurse, midwife, or other trained attendant would be available at all times to assist in answering questions or monitoring the mother and baby’s status as needed, and full-time doulas would also be available to support the mothers.
  4. The most critical step that US maternity services must take is to change their view of labor and birth.  Beginning to see birth as a normal process, not to be interfered with unless absolutely necessary, is an essential first step toward improving maternity outcomes in the United States.

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