title: The distribution of maternity services across rural and remote Australia: does it reflect population need?
abstract: Australia has a universal health care system and a comprehensive safety net. Despite this, outcomes for Australians living in rural and remote areas are worse than those living in cities. This study will examine the current state of equity of access to birthing services for women living in small communities in rural and remote Australia from a population perspective and investigates whether services are distributed according to need.
  
  
  
  Health facilities in Australia were identified and a service catchment was determined around each using a one-hour road travel time from that facility. Catchment exclusions: metropolitan areas, populations above 25,000 or below 1,000, and a non-birthing facility within the catchment of one with birthing. Catchments were attributed with population-based characteristics representing need: population size, births, demographic factors, socio-economic status, and a proxy for isolation - the time to the nearest facility providing a caesarean section (C-section). Facilities were dichotomised by service level - those providing birthing services (birthing) or not (no birthing). Birthing services were then divided by C-section provision (C-section vs no C-section birthing). Analysis used two-stage univariable and multivariable logistic regression.
  
  
  
  There were 259 health facilities identified after exclusions. Comparing services with birthing to no birthing, a population is more likely to have a birthing service if they have more births, (adjusted Odds Ratio (aOR): 1.50 for every 10 births, 95% Confidence Interval (CI) [1.33-1.69]), and a service offering C-sections 1 to 2 h drive away (aOR: 28.7, 95% CI [5.59-148]). Comparing the birthing services categorised by C-section vs no C-section, the likelihood of a facility having a C-section was again positively associated with increasing catchment births and with travel time to another service offering C-sections. Both models demonstrated significant associations with jurisdiction but not socio-economic status.
  
  
  
  Our investigation of current birthing services in rural and remote Australia identified disparities in their distribution. Population factors relating to vulnerability and isolation did not increase the likelihood of a local birthing facility, and very remote communities were less likely to have any service. In addition, services are influenced by jurisdictions.
authors.affiliation: University Centre of Rural Health, University of Sydney, PO Box 3074, Lismore, NSW, 2480, Australia. margaret.rolfe@sydney.edu.au.
authors.forename: Margaret I
authors.initials: MI
authors.lastname: Rolfe
authors.affiliation: University Centre of Rural Health, University of Sydney, PO Box 3074, Lismore, NSW, 2480, Australia.
authors.forename: Deborah Anne
authors.initials: DA
authors.lastname: Donoghue
authors.affiliation: University Centre of Rural Health, University of Sydney, PO Box 3074, Lismore, NSW, 2480, Australia.
authors.forename: Jo M
authors.initials: JM
authors.lastname: Longman
authors.affiliation: University Centre of Rural Health, University of Sydney, PO Box 3074, Lismore, NSW, 2480, Australia.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Pilcher
authors.affiliation: Mater Research Institute, Women's Health and Newborn Services, Mater Health Service, The University of Queensland (UQ), School of Nursing, Midwifery and Social Work, UQ, Brisbane, QLD, 4101, Australia.
authors.forename: Sue
authors.initials: S
authors.lastname: Kildea
authors.affiliation: Institute for Urban Indigenous Health, School of Nursing, Midwifery and Social Work, UQ, Bowen Hills, QLD, 4006, Australia.
authors.forename: Sue
authors.initials: S
authors.lastname: Kruske
authors.affiliation: Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Jude
authors.initials: J
authors.lastname: Kornelsen
authors.affiliation: Centre for Rural Health Research, Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Stefan
authors.initials: S
authors.lastname: Grzybowski
authors.affiliation: University Centre of Rural Health, University of Sydney, PO Box 3074, Lismore, NSW, 2480, Australia.
authors.forename: Lesley
authors.initials: L
authors.lastname: Barclay
authors.affiliation: University Centre of Rural Health, University of Sydney, PO Box 3074, Lismore, NSW, 2480, Australia.
authors.forename: Geoffrey Gerard
authors.initials: GG
authors.lastname: Morgan
mesh_terms: D001315:Australia / Q000453:epidemiology; D001723:Birth Rate; D002585:Cesarean Section; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000706:statistics & numerical data; D006780:Hospitals, Rural; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000458:organization & administration*; D008507:Medically Underserved Area; D008880:Midwifery / Q000458:organization & administration*; D020380:Needs Assessment; D036801:Parturition; D011247:Pregnancy; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population
keywords: Catchment area (health); Geographic information systems; Health services research; Healthcare disparities; Maternity Hospitals; Rural health services