title: The influence of hospital closures in Nova Scotia on perinatal outcomes.
abstract: OBJECTIVE
  To evaluate the effect of hospital closures on critical obstetrical interventions and perinatal outcomes in rural communities in Nova Scotia, Canada.
  
  
  METHODS
  A population-based cohort study was carried out for the years 1988 to 2002, using data extracted from the Nova Scotia Atlee Perinatal Database. Regions of maternal residence were defined geographically and administratively as Eastern, Northern,Western, and Central. The time periods of 1988 to 1993 and 1996 to 2002 were chosen based on the timing of hospital closures. Changes in rates of several perinatal outcomes were examined by region in relation to the extent of hospital closures experienced by that region.
  
  
  RESULTS
  The majority of hospital closures occurred in 1994 to 1995 with the establishment of new health regions, and affected the Western region most profoundly. In comparison with the Central region (relative risk [RR], 0.56; 95% confidence interval [CI], 0.53-0.59), the temporal reduction in the rate of forceps-assisted vaginal delivery was smaller in the Western region (RR, 0.83; 95% CI, 0.76-0.91; P < .001), but greater in the Northern (RR, 0.36; 95% CI, 0.32-0.41; P < .001) and Eastern (RR, 0.26; 95% CI, 0.23-0.30; P < .001) regions. The temporal increase in the rate of breastfeeding at discharge from hospital was smaller in the Northern region (RR, 1.36; 95% CI, 1.29-1.45; P < .001) compared to that in the Central region (RR, 1.55; 95% CI, 1.49-1.61). The decrease in the rate of fetal growth restriction was smaller in the Western (RR, 0.95; 95% CI, 0.87-1.02; P = .002) and Eastern (RR, 0.90; 95% CI, 0.82-0.98; P = .002) regions of residence compared to the Central region (RR, 0.75; 95% CI, 0.71-0.79). There were no significant regional differences in temporal patterns of preterm induction and/or preterm Caesarean delivery, or perinatal mortality.
  
  
  CONCLUSIONS
  Although trends over time demonstrated some regional differences in obstetrical interventions and perinatal outcomes, our retrospective evaluation did not reveal a consistent relationship between reductions in maternity services associated with hospital closures and systematic, population-level adverse perinatal consequences in Nova Scotia.
authors.affiliation: Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Victoria M
authors.initials: VM
authors.lastname: Allen
authors.forename: Nadia
authors.initials: N
authors.lastname: Jilwah
authors.forename: K S
authors.initials: KS
authors.lastname: Joseph
authors.forename: Linda
authors.initials: L
authors.lastname: Dodds
authors.forename: Colleen M
authors.initials: CM
authors.lastname: O'Connell
authors.forename: Edwin R
authors.initials: ER
authors.lastname: Luther
authors.forename: T John
authors.initials: TJ
authors.lastname: Fahey
authors.forename: Rebecca
authors.initials: R
authors.lastname: Attenborough
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Allen
mesh_terms: D000328:Adult; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D006271:Health Facility Closure; D006801:Humans; D009674:Nova Scotia; D018743:Perinatal Care / Q000592:standards* / Q000639:trends; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D012423:Rural Health