Consolidación universitaria de la disciplina

Driving aspects of regionalisation was the lurking suspicion that birth in a rural facility was a risky affair. This perception meant that rural maternity services were obliged to prove their safety within a rapidly moving environment of regionalisation and hospital closures (Rosenblatt, 1984). It was suggested that officials saw rural units at the time as “inefficient, over bedded, underutilized, difficult to manage and of questionable quality” (p.31). However there was no evidence for these assertions, prompting the impression that while the first wave of closures was about quality of care, the second was more about economic stringency (ibid).

The question of safety was addressed in a study by Rosenblatt et al., (1985). Data from the National Health Statistics Centre of New Zealand and government publications were merged and analysed with regard to the hospital level; i.e. 1, 2 or 3. The results showed that all but the lower birth weight babies fared better in the smaller, level one units (ibid). The authors concluded that these results were related to the level of regionalisation extant at that time, combined with cautious antenatal referral practices of GPs. It was also contended that there was no justification for further closures.

The data do not support the conclusion that there is some minimum threshold below which maternity units become unsafe places in which to practice obstetrics. Rather the evidence implied that the small, decentralised unit can do a good job if it is tied securely into a larger regional network of care (Rosenblatt, 1984).

Similar findings about the safety of birth in small rural hospitals were found in Australia. A study by Lumley (1988) assessed the perinatal outcomes in the state of Victoria between 1982 and 1984. At the time, no “formal policy of regionalised perinatal care and…no established policy of closing small maternity units” (p.386) existed in Victoria. Results appeared to confirm that infants weighing between 2500 to 2999g “fared worse in larger hospitals” (p.390).

Also under question was the minimum number of births necessary for safe practice (Tilyard, Williams, Seddon, Oakley & Campbell, 1988). This was formalised in New Zealand in 1972 when the Department of Health recommended that practitioners should deliver more than 50 babies per year. This was later reduced to greater than 20 per year by the Waikato maternity services development group.

In response Tilyard et al., (1988) looked at the outcomes for general practitioner obstetricians with regard to their workload and locality. The case notes for all deliveries (1,997 births) at Queen Mary Maternity Hospital in Dunedin, between

variables were explored. The first compared the results of rural and urban practitioners and the second compared those delivering 20 or more women per year with those who delivered less than 20. Findings showed that rural GPs were more stringent in their selection of women deemed suitable to birth locally, but no difference was found in the transfer patterns for both groups during labour. Rather, rural practitioners delivering more than 20 had the lowest rates of transfer overall (ibid). Thus, “[n]o association was found between the number of deliveries undertaken by general practitioners, both urban and rural and maternal and neonatal morbidity” (Tilyard et al., 1988, p.207). The authors suggested that these results indicated that the rural practitioners used sensitive screening techniques during pregnancy to exclude women with risk factors. Further, that those with higher caseloads may be more competent at managing abnormalities as they arise thus transferring less often.

Debates about safety and the closure of rural maternity beds were of concern elsewhere. Tew (1995) reported that in the United Kingdom, almost half the GP maternity beds closed between 1980 and 1990. These closures were driven by the safety argument based on studies that compared outcomes between consultant units and those managed by GPs and midwives (ibid). One such study compared the outcome results of 14,415 women from a consultant unit with those from isolated and integrated GP units (Sangala, Dunster, Bohin & Osborne, 1990). The results demonstrated that the perinatal death rate was unacceptably high even with high risk pregnancies removed from the data; being 2.8 compared to 4.8 per 1000 births respectively. In addition a significant number of babies, 1.5 per 1000 births, died of antepartum or intrapartum asphyxia due to a range of known and unknown causes in the GP units. The researchers suggested that while “[m]uch has been written about the psychological importance of a normal delivery in friendly surroundings, …the psychological effects of losing a baby, particularly if the death was preventable, are enormous and long lasting” (420).

However a later analysis of 50,000 births failed to show that women and their babies were at greater risk in the GP units (Campbell & McFarlane, 1994). It was suggested that the closures of GP units were not just in response to claims

of risk and distance from specialist services, but also the lack of economic viability (ibid). There was no assessment of the cost of the proposed changes, thus, expenses were shifted to individuals and communities where they were unable to be tracked and evaluated (ibid). In response maternity services were investigated by the Health Committee of the House of Commons (Tew, 1995). This inquiry took women’s concerns seriously and in 1992 the Winterton Report was published. The report found no justification for encouraging hospital birth on the basis of safety, and further, that home birth and small maternity units should be supported (Tew, 1995).

Voluntary regionalisation was also promoted in Nova Scotia, Canada (Peddle, Brown, Buckley, Dixon, Kaye, Muise, et al., 1983). Like New Zealand the move was based on the assumption that the already declining neonatal mortality rate could be lowered further (ibid). Women in remote and isolated areas were offered obstetric and neonatal care relative to their risk. A series of inspections and programmes were offered and a three tier hospital system instituted with level one reserved for low risk women (ibid). When these changes were evaluated, it was difficult to attribute improved perinatal outcomes to the regionalisation programme, as controlled clinical trials were not feasible or ethical (ibid). Thus the improved statistics could only be related ‘theoretically’ to the programme changes (ibid).

Reduction in maternity services in most Commonwealth countries went hand in hand with cutbacks in other areas of rural health. Not least of these were the surgical and anaesthetic services provided at provincial hospitals. Where these were withdrawn in New Zealand protests were bitter and protracted. Yule (2002) comments, that by the 1980s GP –surgeons had largely disappeared, partly due to the demand for rigorous adherence to standards of practice required by the relevant professional bodies (ibid). For countries where vast distances separated rural maternity hospitals from specialist facilities, the loss of on site, emergency surgical services was seen to be of even greater concern.