Obstetric Care in Norway - A Collaborative and Knowledge-building project

Obstetric care in Norway- a competence-building collaborative project at the Norwegian Institute of Public Health Knowledge about how availability of different types of obstetric institutions and the place of delivery impacts maternal and fetal/neonatal outcomes during pregnancy and delivery is lacking. In Norway the number of obstetric institutions was reduced substantially during the last five decades, resulting in increasing travel time to the nearest obstetric institution for women and increasing geographic inequalities in delivery outcomes following reduced access. This research project aims to contribute new and better knowledge about how access to different types of obstetric institutions and the place of delivery impacts risk of severe complications and death for the women and fetus/newborn during pregnancy and delivery, with a particular focus on vulnerable groups such as migrant and rural women. The project is a collaboration with obstetricians at the Departments of Obstetrics and Gynecology in Stavanger, Bergen and Drammen, with the Norwegian Midwives Association and the Norwegian Centre for Research on Women?s Health. The Norwegian Society of Obstetrics and Gynecology and the Norwegian Women?s Public Health Association are user representatives. With our partners we aim to develop new and better measures and monitoring of severe complications for women during pregnancy and childbirth by using both national health registry data and audit analyses of the care provision process for women who experience severe complications but survive. We will also study severe complications in the newborn and fetal/newborn deaths. A major aim is to study how the estimated travel time from a woman?s home to the nearest obstetric institution is associated with increased risk of severe complications for the woman and fetus/newborn babies. The travel time estimates are made using individual geographic data, which is unique in our study. International comparisons will further contribute to knowledge about how the health services can prevent severe complications. The results will reveal barriers women face to receive the right health care at the right time and may inform mitigating measures to reduce social inequalities in health.

Knowledge of how availability of and access to different types of obstetric institutions (OI) impact maternal and perinatal clinical outcomes in high-income contexts is lacking. Our previous results showed increased geographic differences in availability of OI over time, and associations between longer travel time to nearest OI and adverse maternal and perinatal outcomes. We will use updated geographic information to estimate individual travel time to the nearest OI for women who delivered in the study period, and assess severe maternal morbidity (SMM), perinatal mortality and neonatal morbidity by travel time and place of delivery, using WHO guidelines and volume to classify institutions. Analysing outcomes across population groups can yield important information about barriers to receive timely and appropriate care, such barriers may differ between vulnerable groups. Case-review audits based on data from women who experience severe, potentially life-threatening morbidity but survive yield further knowledge about successes and barriers to provision of appropriate healthcare. We will validate diagnosis- and treatment-based definitions of SMM and evaluate the possibilities to routinely monitor SMM on a national scale. National and international comparisons may yield valuable information concerning health care practices preventing severe morbidity or death. The collaboration with obstetric clinicians and the Norwegian Midwives Association is novel and key to inform and implement results according to clinical needs. The project uses linked data from the Medical Birth Registry of Norway with 1.1 mill deliveries 1999-2018, the Norwegian Patient Registry, and individual geographic address coordinates from Statistics Norway. For case audits we will use Mothers and Babies Reducing Risk through Audits and Confidential Enquiries forms (MBRRACE; UK). The results will inform public debate, health policy descisions, clinical care and enable informed descisions for women.