title: Where does distance matter? Distance to the closest maternity unit and risk of foetal and neonatal mortality in France.
abstract: BACKGROUND
  The number of maternity units has declined in France, raising concerns about the possible impact of increasing travel distances on perinatal health outcomes. We investigated impact of distance to closest maternity unit on perinatal mortality.
  
  
  METHODS
  Data from the French National Vital Statistics Registry were used to construct foetal and neonatal mortality rates over 2001-08 by distance from mother's municipality of residence and the closest municipality with a maternity unit. Data from French neonatal mortality certificates were used to compute neonatal death rates after out-of-hospital birth. Relative risks by distance were estimated, adjusting for individual and municipal-level characteristics.
  
  
  RESULTS
  Seven percent of births occurred to women residing at ≥30 km from a maternity unit and 1% at ≥45 km. Foetal and neonatal mortality rates were highest for women living at <5 km from a maternity unit. For foetal mortality, rates increased at ≥45 km compared with 5-45 km. In adjusted models, long distance to a maternity unit had no impact on overall mortality but women living closer to a maternity unit had a higher risk of neonatal mortality. Neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances. At the municipal-level, higher percentages of unemployment and foreign-born residents were associated with increased mortality.
  
  
  CONCLUSIONS
  Overall mortality was not associated with living far from a maternity unit. Mortality was elevated in municipalities with social risk factors and located closest to a maternity unit, reflecting the location of maternity units in deprived areas with risk factors for poor outcome.
authors.affiliation: 1 Département de Géographie, Université Paris 8 Vincennes-Saint-Denis, UMR7533 Ladyss, 2 rue de la Liberté, F-93526 Saint-Denis, France hugo.pilkington@univ-paris8.fr.
authors.forename: Hugo
authors.initials: H
authors.lastname: Pilkington
authors.affiliation: 2 INSERM, UMRS 953, Epidemiological Research Unit on Perinatal and Women's and Children's Health, Paris, France 3 UPMC University Paris06, Paris, France.
authors.forename: Béatrice
authors.initials: B
authors.lastname: Blondel
authors.affiliation: 2 INSERM, UMRS 953, Epidemiological Research Unit on Perinatal and Women's and Children's Health, Paris, France 3 UPMC University Paris06, Paris, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Drewniak
authors.affiliation: 2 INSERM, UMRS 953, Epidemiological Research Unit on Perinatal and Women's and Children's Health, Paris, France 3 UPMC University Paris06, Paris, France.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Zeitlin
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005313:Fetal Death; D005602:France / Q000453:epidemiology; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000458:organization & administration*; D008875:Middle Aged; D011247:Pregnancy; D012042:Registries; D012306:Risk; D012307:Risk Factors; D014195:Travel