Abstract
BackgroundIn Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly. Obstetrics services should be concentrated in fewer hospitals to improve quality of care and reduce the workload of obstetricians. However, the impact of this intensification of services on access to obstetrics hospitals is not known. We undertook a simulation to examine how the intensification of obstetrics services would affect access to hospitals based on a variety of scenarios, and the implications for health policy.MethodsThe female population aged between 15 and 49 living within a 30-min drive of an obstetrics hospital was calculated using a Geographic Information System for three possible intensification scenarios: Scenario 1 retained facilities with a higher volume of deliveries without considering the geographic boundaries of Medical Service Areas (MSAs, zones of healthcare administration and management); Scenario 2 prioritized retaining at least one hospital in each MSA and then retained higher delivery volume institutions, while Scenario 3 retained facilities to maximize population coverage using location-allocation modeling. We also assessed the impact of concentrating services in academic hospitals and specialist perinatal medical centers (PMCs) alone.ResultsIn 2011, 95.0 % of women aged 15–49 years lived within a 30-min drive of one of 1075 obstetrics hospitals. This would fall to 82.7 % if obstetrics services were intensified into academic hospitals and general and regional PMCs. If 55.0 % of institutions provided obstetrics services, the coverage would be 87.6 % in Scenario 1, whereas intensification based on access would achieve over 90.5 % coverage in Scenario 2 and 93.9 % in Scenario 3.ConclusionsIntensification of obstetrics facilities impairs access, but a greater caseload and better staffing have the potential advantages of better clinical outcomes and reduced costs. It is essential to consult residents of hospital catchment areas when reorganizing clinical services; a simulation is a useful means of informing these important discussions.
Highlights
In Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly
We considered intensification into academic hospitals and perinatal medical centers only, and three other scenarios: (1) consider only the number of deliveries so as to maximize quality and minimize cost; (2) consider only maximizing accessibility; and (3) a combination of (1) and (2)
The regional and general perinatal medical center (PMC) had a lower number of deliveries per obstetrician and a greater proportion of deliveries by cesarean section (Table 2)
Summary
In Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly. Obstetrics services should be concentrated in fewer hospitals to improve quality of care and reduce the workload of obstetricians. The impact of this intensification of services on access to obstetrics hospitals is not known. In healthcare the correct balance between quality, cost and access are difficult to achieve, and provision of clinical obstetrics services is no exception. Other studies have examined the effect of hospital closure on neonatal and infant mortality [3, 4]. A study of maternal deaths occurring in Japan suggested that the intensification of obstetrics services to avoid singleobstetrician facilities reduces maternal mortality [5]. Even if closure of hospitals can achieve better quality of care as well as reducing the burden on obstetricians and midwives, public opinion is often firmly against hospital closures because of the impact on access to healthcare services. Reducing hospital services has political implications that may override technical considerations [6]
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