Abstract
Objectives of this study, based on an analysis of births and infant deaths in mainland France between 2013 and 2022, were: -a) to assess the annual number of births recorded in municipalities without maternity wards (out-of-hospital deliveries) and to analyze the trend in relation to the closure of maternity wards; -b) to estimate the excess risk of neonatal and infant mortality associated with out-of-hospital deliveries and the proportion of excess mortality attributable to them; -c) using routinely available data characterizing the environment, to identify the areas most at risk of out-of-hospital deliveries that would require specific interventions in the field of perinatal care.
Results: During this period, 0.48% of births (35,732 births) were recorded in 26,657 municipalities without a maternity ward. This rate increased from 0.37% in 2013 to 0.65% in 2022, while the number of towns with a maternity ward fell from 416 to 373. The risk of out‑of‑hospital delivery increases with the distance to the nearest maternity ward. A positive gradient is recorded from 30 km (1.7 from 31 km to 45 km; 2.4 from 46 km to 60 km and 3.0 from 61 km). The risk is multiplied by 1.3 in cases of difficulty accessing primary care services and by 1.8 when the woman lives in a rural municipality.
The risks of out‑of‑hospital deliveries are unevenly distributed across the mainland area. In 2022, only 15 out of 96 departments had an out‑of‑hospital deliveries rate below the national average. These departments had fewer rural municipalities and more large urban areas, less difficulty accessing primary care, and shorter distances to the nearest maternity ward. The number of pregnant women living more than 30 km from a maternity ward was 6.5 times lower than in the rest of mainland France.
The risks of infant and neonatal mortality, which are higher among out-of-hospital deliveries, are responsible for an excess of 204 deaths before the age of 1 and 180 neonatal deaths between 2013 and 2022. This excess neonatal mortality accounts for 2.71% of the excess neonatal mortality recorded in France between 2015 and 2017.