Lisonkova Sarka, Haslam Matthew D, Dahlgren Leanne, Chen Innie, Synnes Anne R, Lim Kenneth I
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC
Department of Obstetrics and Gynaecology (Lisonkova, Dahlgren, Lim), University of British Columbia and the Children's and Women's Health Centre of British Columbia; School of Population and Public Health (Lisonkova, Haslam), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Chen), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC.
CMAJ. 2016 Dec 6;188(17-18):E456-E465. doi: 10.1503/cmaj.151382. Epub 2016 Sep 26.
Most studies examining geographic barriers to maternity care in industrialized countries have focused solely on fetal and neonatal outcomes. We examined the association between rural residence and severe maternal morbidity, in addition to perinatal mortality and morbidity.
We conducted a retrospective population-based cohort study of all women who gave birth in British Columbia, Canada, between Jan. 1, 2005, and Dec. 31, 2010. We compared maternal mortality and severe morbidity (e.g., eclampsia) and adverse perinatal outcomes (e.g., perinatal death) between women residing in areas with moderate to no metropolitan influence (rural) and those living in metropolitan areas or areas with a strong metropolitan influence (urban). We used logistic regression analysis to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs).
We found a significant association between death or severe maternal morbidity and rural residence (adjusted OR 1.15, 95% CI 1.03-1.28). In particular, women in rural areas had significantly higher rates of eclampsia (adjusted OR 2.70, 95% CI 1.79-4.08), obstetric embolism (adjusted OR 2.16, 95% CI 1.14-4.07) and uterine rupture or dehiscence (adjusted OR 1.96, 95% CI 1.42-2.72) than women in urban areas. Perinatal mortality did not differ significantly between the study groups. Infants in rural areas were more likely than those in urban areas to have a severe neonatal morbidity (adjusted OR 1.14, 95% CI 1.02-1.29), to be born preterm (adjusted OR 1.06, 95% CI 1.01-1.11), to have an Apgar score of less than 7 at 5 minutes (adjusted OR 1.24, 95% CI 1.13-1.31) and to be large for gestational age (adjusted OR 1.14, 95% CI 1.10-1.19). They were less likely to be small for gestational age (adjusted OR 0.90, 95% CI 0.85-0.95) and to be admitted to an neonatal intensive care unit (NICU) (adjusted OR 0.36, 95% CI 0.33-0.38) compared with infants in urban areas.
Compared with women in urban areas, those in rural areas had higher rates of severe maternal morbidity and severe neonatal morbidity, and a lower rate of NICU admission. Maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care.
大多数研究工业化国家孕产妇保健地理障碍的研究仅关注胎儿和新生儿结局。我们除了研究围产期死亡率和发病率外，还研究了农村居住与严重孕产妇发病之间的关联。
我们对2005年1月1日至2010年12月31日期间在加拿大不列颠哥伦比亚省分娩的所有妇女进行了一项基于人群的回顾性队列研究。我们比较了居住在受大都市影响中等或无影响地区（农村）的妇女与居住在大都市地区或受大都市影响强烈地区（城市）的妇女的孕产妇死亡率和严重发病率（如子痫）以及不良围产期结局（如围产期死亡）。我们使用逻辑回归分析来获得调整后的优势比（OR）和95%置信区间（CI）。
我们发现死亡或严重孕产妇发病与农村居住之间存在显著关联（调整后的OR为1.15，95%CI为1.03 - 1.28）。特别是，农村地区的妇女患子痫（调整后的OR为2.70，95%CI为1.79 - 4.08）、产科栓塞（调整后的OR为2.16，95%CI为1.14 - 4.07）以及子宫破裂或裂开（调整后的OR为1.96，95%CI为1.42 - 2.72）的发生率显著高于城市地区的妇女。研究组之间的围产期死亡率没有显著差异。与城市地区的婴儿相比，农村地区的婴儿患严重新生儿疾病的可能性更高（调整后的OR为1.14，95%CI为1.02 - 1.29），早产的可能性更高（调整后的OR为1.06，95%CI为1.01 - 1.11），5分钟时阿氏评分低于7分的可能性更高（调整后的OR为1.24，95%CI为1.13 - 1.31），且大于胎龄的可能性更高（调整后的OR为1.14，95%CI为1.10 - 1.19）。与城市地区的婴儿相比，他们小于胎龄的可能性更低（调整后的OR为0.90，95%CI为0.85 - 0.95），入住新生儿重症监护病房（NICU）的可能性更低（调整后的OR为0.36，95%CI为0.33 - 0.38）。
与城市地区的妇女相比，农村地区的妇女严重孕产妇发病率和严重新生儿发病率更高，且入住NICU的比例更低。农村地区的孕产妇保健提供者需要意识到可能危及生命的孕产妇和围产期并发症，这些并发症需要先进的产科和新生儿护理。
