title: The impact on neonatal mortality of shifting childbirth services among levels of hospitals: Taiwan's experience.
abstract: BACKGROUND
  There is considerable discussion surrounding whether advanced hospitals provide better childbirth care than local community hospitals. This study examines the effect of shifting childbirth services from advanced hospitals (i.e., medical centers and regional hospitals) to local community hospitals (i.e., clinics and district hospitals). The sample population was tracked over a seven-year period, which includes the four months of the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan. During the SARS epidemic, pregnant women avoided using maternity services in advanced hospitals. Concerns have been raised about maintaining the quality of maternity care with increased demands on childbirth services in local community hospitals. In this study, we analyzed the impact of shifting maternity services among hospitals of different levels on neonatal mortality and maternal deaths.
  
  
  METHODS
  A population-based study was conducted using data from Taiwan's National Health Insurance annual statistics of monthly county neonatal morality rates. Based on a pre-SARS sample from January 1998 to December 2002, we estimated a linear regression model which included "trend," a continuous variable representing the effect of yearly changes, and two binary variables, "month" and "county," controlling for seasonal and county-specific effects. With the estimated coefficients, we obtained predicted neonatal mortality rates for each county-month. We compared the differences between observed mortality rates of the SARS period and predicted rates to examine whether the shifting in maternity services during the SARS epidemic significantly affected neonatal mortality rates.
  
  
  RESULTS
  With an analysis of a total of 1,848 observations between 1998 and 2004, an insignificantly negative mean of standardized predicted errors during the SARS period was found. The result of a sub-sample containing areas with advanced hospitals showed a significant negative mean of standardized predicted errors during the SARS period. These findings indicate that despite increased use of local community hospitals, neonatal mortality during the SARS epidemic did not increase, and even decreased in areas with advanced hospitals.
  
  
  CONCLUSIONS
  An increased use of maternity services in local community hospitals occurred during the SARS epidemic in Taiwan. However, we observed no increase in neonatal and maternity mortality associated with these increased demands on local community hospitals.
authors.affiliation: Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN 55414, USA. wang1018@umn.edu
authors.forename: Shi-Yi
authors.initials: SY
authors.lastname: Wang
authors.forename: Sylvia H
authors.initials: SH
authors.lastname: Hsu
authors.forename: Li-Kuei
authors.initials: LK
authors.lastname: Chen
mesh_terms: D005260:Female; D006302:Health Services Research; D006739:Hospital Administration; D006801:Humans; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D016014:Linear Models; D008297:Male; D008427:Maternal Health Services / Q000458:organization & administration*; D008428:Maternal Mortality; D011247:Pregnancy; D012307:Risk Factors; D045169:Severe Acute Respiratory Syndrome / Q000453:epidemiology; D013624:Taiwan / Q000453:epidemiology