Holowko Natalie, Ladfors Linnea V, Örtqvist Anne K, Ahlberg Mia, Stephansson Olof
Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
Department of Women's Health, Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden.
Acta Obstet Gynecol Scand. 2025 Jan;104(1):55-67. doi: 10.1111/aogs.14980. Epub 2024 Nov 17.
In recent decades, centralization of health care has resulted in a number of obstetric unit closures. While studies support better infant outcomes in larger facilities, few have investigated maternal outcomes. We investigated obstetric unit closures over time and whether obstetric volume is associated with onset of labor, postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS).
All births registered in Sweden between 1992 and 2019 (Medical Birth Register, N = 2 931 140), linked with data on sociodemographic characteristics and maternal/infant diagnoses, were used to describe obstetric unit closures. After excluding congenital malformations, obstetric volume was categorized (low: 0-1999, medium: 2000-3999, high: ≥4000 births per year). Restricting to 2004 onwards (after most closures), the association between volume and onset of labor (spontaneous as reference) was estimated. Restricting to spontaneous, full-term (≥37 weeks gestation) cephalic births, we then investigated the association between volume and PPH and, after excluding planned cesarean sections, OASIS. Odds ratios from multilevel (logistic) models clustered by hospital were estimated.
The 20 dissolved obstetric units (1992-2019) had relatively stable volume until their closure. Compared to the average, women birthing in the highest volume hospitals were older (31.3 years vs. 30.4) and a higher proportion had >12 years of education (57 vs. 51%). Compared to high-volume hospitals, there was no significant difference in labor starting by elective cesarean section or induction, rather than spontaneously, among low (OR 0.88, 95% CI: 0.73-1.06) and medium (OR 0.84, 95% CI 0.71-1.01) volume hospitals. There were lower odds of PPH among low (OR 0.72, 95% CI 0.63-0.85) and medium (OR 0.83, 95% CI 0.72-0.97) volume hospitals. No significant association was found between obstetric volume and OASIS (low: OR 0.98, 95% CI 0.82-1.18; medium: OR 0.90, 95% CI 0.77-1.05).
There was not a strong relationship between obstetric volume and maternal outcomes. Reduced odds of PPH for women birthing in smaller units may be due to triaging high-risk pregnancies to larger hospitals. While there was no significant association between obstetric volume and onset of labor or OASIS, other important factors related to closures, such as workload and overcrowding, should be investigated.
近几十年来，医疗保健的集中化导致了一些产科病房的关闭。虽然研究表明在较大的医疗机构中婴儿结局更好，但很少有研究调查产妇结局。我们调查了产科病房随时间的关闭情况，以及产科分娩量是否与分娩发动、产后出血（PPH）和产科肛门括约肌损伤（OASIS）有关。
1992年至2019年在瑞典登记的所有分娩（医疗出生登记册，N = 2931140），与社会人口学特征和母婴诊断数据相关联，用于描述产科病房的关闭情况。排除先天性畸形后，将产科分娩量分类（低：每年0 - 1999例，中：每年2000 - 3999例，高：≥4000例分娩）。限制在2004年以后（大多数关闭之后），估计分娩量与分娩发动（以自然分娩为参照）之间的关联。限制在自然分娩、足月（≥37周妊娠）头位分娩，然后我们调查分娩量与PPH之间的关联，并且在排除计划剖宫产之后，调查与OASIS的关联。估计由医院聚类的多水平（逻辑）模型的比值比。
20个关闭的产科病房（1992 - 2019年）在关闭前分娩量相对稳定。与平均水平相比，在分娩量最高的医院分娩的女性年龄更大（31.3岁对30.4岁），且受教育超过12年的比例更高（57%对51%）。与高分娩量医院相比，低分娩量（比值比0.88，95%置信区间：0.73 - 1.06）和中分挽量（比值比0.84，95%置信区间0.71 - 1.01）医院通过择期剖宫产或引产而非自然分娩发动的情况没有显著差异。低分娩量（比值比0.72，95%置信区间0.63 - 0.85）和中分挽量（比值比0.83，95%置信区间0.72 - 0.97）医院发生PPH的几率较低。未发现产科分娩量与OASIS之间存在显著关联（低：比值比0.98，95%置信区间0.82 - 1.18；中：比值比0.90，95%置信区间0.77 - 1.05）。
产科分娩量与产妇结局之间没有很强的关系。在较小单位分娩的女性PPH几率降低可能是由于将高危妊娠分流到较大医院。虽然产科分娩量与分娩发动或OASIS之间没有显著关联，但应调查与关闭相关的其他重要因素，如工作量和过度拥挤情况。
