Births out of Hospital in France: Trends from 2013 to 2022, Infant Mortality and Risk Factors
Main Article Content
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.
Article Details
How to Cite
EVELYNE, Combier; JONATHAN, Cottenet; CATHERINE, Quantin.
Births out of Hospital in France: Trends from 2013 to 2022, Infant Mortality and Risk Factors.
Medical Research Archives, [S.l.], v. 14, n. 1, jan. 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7195>. Date accessed: 03 feb. 2026.
doi: https://doi.org/10.18103/mra.v14i1.7195.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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2. Papon S. La mortalité infantile est stable depuis dix ans après des décennies de baisse - Insee Focus - 117. Accessed May 19, 2025. https://www.insee.fr/fr/statistiques/3560308
3. Sartorius V, Philibert M, Klungsoyr K, et al. Neonatal Mortality Disparities by Gestational Age in European Countries. JAMA Netw Open. 2024;7(8):e2424226. doi:10.1001/jamanetworkopen.2024.24226
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5. Cortes A, Leurquin S. 4,1 Le scandale des accouchements en France. Buchel Chastel; 2025.
6. Cour des Comptes. La politique de périnatalité. Des résultats sanitaires médiocres, une mobilisation à amplifier; 2024. Accessed May 17, 2025. https://www.ccomptes.fr/fr/documents/69727
7. Vigneron E. Inégalités de santé, inégalités de soins dans les territoires français. Bull Académie Natl Médecine. 2012;196(4):939-952. doi:10.1016/S0001-4079(19)31781-9
8. Puech F. Le temps, les temporalités et l’état de l’organisation des soins en périnatalité en France. Périnatalité. 2019;11(2):73-77. doi:10.3166/rmp-2019-0049
9. Coldefy M, Com-Ruelle L, Lucas-Gabrielli V. Distances et temps d’accès aux soins en France métropolitaine. IRDES - Quest Déconomie Santé. 2011;(164). Accessed November 28, 2025. http://www.irdes.fr/Publications/2011/Qes164.pdf
10. Haut Comité de Santé Publique. La sécurité et la qualité de la grossesse et de la naissance: pour un nouveau plan périnatalité. ENSP; 1994.
11. NHS University of York. Hospital volume and health care outcomes,cost and patient access. Eff Health Care. 1996;2(8). Accessed October 29, 2025. https://www.york.ac.uk/media/crd/ehc28.pdf
12. Heller G, Richardson DK, Schnell R, Misselwitz B, Künzel W, Schmidt S. Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990–1999. Int J Epidemiol. 2002;31(5):1061-1068. doi:10.1093/ije/31.5.1061
13. Ville Y, Rudigoz RC, Hascoët JM. Rapport 23-05. Planification d’une politique en matière de périnatalité en France : organiser la continuité des soins est une nécessité et une urgence. Bull Académie Natl Médecine. 2023;207(5):560-575. doi:10.1016/j.banm.2023.03.017
14. CNGOF. Pérennité des équipes, quel avenir pour la continuité des soins en gynécologie obstétrique?; Commission démographie: rapport 2022.
15. Charreire H, Combier E, Michaut F, et al. Une géographie de l’offre de soins en restructuration : les territoires des maternités en Bourgogne. Cah Géographie Qué. 2011;55(156):491-509. doi:10.7202/1008891ar
16. Blondel B, Drewniak N, Pilkington H, Zeitlin J. Out-of-hospital births and the supply of maternity units in France. Health Place. 2011;17(5):1170-1173. doi:10.1016/j.healthplace.2011.06.002
17. Combier E, Charreire H, Le Vaillant M, et al. Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy. Health Place. 2013;24:225-233. doi:10.1016/j.healthplace.2013.09.006
18. Kildea S, McGhie AC, Gao Y, Rumbold A, Rolfe M. Babies born before arrival to hospital and maternity unit closures in Queensland and Australia. Women Birth. 2015;28(3):236-245. doi:10.1016/j.wombi.2015.03.003
19. Pilkington H. Risques cachés de l’accouchement en France : les défis des naissances inopinées hors maternité. The Conversation. doi:10.64628/AAK.r4add9utm
20. Engjom HM, Morken NH, Høydahl E, Norheim OF, Klungsøyr K. Increased risk of peripartum perinatal mortality in unplanned births outside an institution: a retrospective population-based study. Am J Obstet Gynecol. 2017;217(2):210.e1-210.e12 . doi:10.1016/j.ajog.2017.03.033
21. Huotari T, Rusanen J, Keistinen T, et al. Effect of centralization on geographic accessibility of maternity hospitals in Finland. BMC Health Serv Res. 2020;20(1):337. doi:10.1186/s12913-020-05222-5
22. Bergonzoni A, Simon M. La part des femmes en âge de procréer résidant à plus de 45 minutes d’une maternité augmente entre 2000 et 2017 |. DREES Etudes Résultats. 2021;(1201). Accessed May 6, 2025. https://drees.solidarites-sante.gouv.fr/publications/etudes-et-resultats/la-part-des-femmes-en-age-de-procreer-residant-plus-de-45-minutes
23. Örtqvist AK, Haas J, Ahlberg M, Norman M, Stephansson O. Association between travel time to delivery unit and unplanned out-of-hospital birth, infant morbidity and mortality: A population-based cohort study. Acta Obstet Gynecol Scand. 2021;100(8):1478-1489. doi:10.1111/aogs.14156
24. Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res. 2011;11:147. doi:10.1186/1472-6963-11-147
25. Pilkington H, Blondel B, Carayol M, Breart G, Zeitlin J. Impact of maternity unit closures on access to obstetrical care: The French experience between 1998 and 2003. Soc Sci Med. 2008;67(10):1521-1529. doi:10.1016/j.socscimed.2008.07.021
26. Gunnarsson B, Smárason AK, Skogvoll E, Fasting S. Characteristics and outcome of unplanned out-of-institution births in Norway from 1999 to 2013: a cross-sectional study. Acta Obstet Gynecol Scand. 2014;93(10):1003-1010. doi:10.1111/aogs.12450
27. Viisainen K, Gissler M, Hartikainen AL, Hemminki E. Accidental out-of-hospital births in Finland: incidence and geographical distribution 1963-1995. Acta Obstet Gynecol Scand. 1999;78(5):372-378.
28. Ovaskainen K, Ojala R, Tihtonen K, Gissler M, Luukkaala T, Tammela O. Unplaned out-of-hospital deliveries in Finland: A national register study on incidence, characteristics maternal and infant outcomes. Acta Obstet Gynecol Scand. 2020;99(12):1691-1699. doi:10.1111/aogs.13947
29. Hemminki E, Heino A, Gissler M. Should births be centralised in higher level hospitals? Experiences from regionalised health care in Finland. BJOG Int J Obstet Gynaecol. 2011;118(10):1186-1195. doi:10.1111/j.1471-0528.2011.02977.x
30. Engjom H, Morken NH, Norheim O, Klungsøyr K. Availability and access in modern obstetric care: a retrospective population-based study. BJOG Int J Obstet Gynaecol. 2014;121(3):290-299. doi:10.1111/1471-0528.12510
31. Combier E, Roussot A, Chabernaud JL, Cottenet J, Rozenberg P, Quantin C. Out-of-maternity deliveries in France: A nationwide population-based study. PloS One. 2020;15(2):e0228785. doi:10.1371/journal.pone.0228785
32. Aoshima K, Kawaguchi H, Kawahara K. Neonatal mortality rate reduction by improving geographic accessibility to perinatal care centers in Japan. J Med Dent Sci. 2011;58(2):29-40.
33. Ravelli A, Jager K, De Groot M, et al. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands: Travel time and adverse perinatal outcomes in women at term. BJOG Int J Obstet Gynaecol. 2011;118(4):457-465. doi:10.1111/j.1471-0528.2010.02816.x
34. Levaillant M, Garabédian C, Legendre G, et al. In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study. Int J Gynecol Obstet. 2024;164(1):210-218. doi:10.1002/ijgo.15004
35. Beeram M, Solarin K, Young M, Abedin M. Morbidity and Mortality of Infants Born Before Arrival at the Hospital. Clin Pediatr (Phila). 1995;34(6):313-316. doi:10.1177/000992289503400604
36. Bonal M, Padilla C, Chevillard G, Lucas-Gabrielli V. A French classification to describe medical deserts: a multi-professional approach based on the first contact with the healthcare system. Int J Health Geogr. 2024;23(1):5. doi:10.1186/s12942-024-00366-7
37. Lapinte A, Legendre B. Renoncement aux soins : la faible densité médicale est un facteur aggravant pour les personnes pauvres. DREES Etudes et résultats N°1200. July 28, 2021. Accessed May 19, 2025. https://www.drees.solidarites-sante.gouv.fr/publications/etudes-et-resultats/renoncement-aux-soins-la-faible-densite-medicale-est-un-facteur
38. DREES. L’indicateur d’accessibilité potentielle localisée (APL) | Direction de la recherche, des études, de l’évaluation et des statistiques. Accessed May 18, 2025. https://drees.solidarites-sante.gouv.fr/sources-outils-et-enquetes/lindicateur-daccessibilite-potentielle-localisee-apl
39. Rumeau-Rouquette C, Bréart G, Padieu R. Méthodes en épidémiologie: Échantillonnage, investigations, analyse. Flammarion Médecine Sciences. Médecine Sciences Publications; 1985.
40. Rollet C, Le Ray C, Vendittelli F, Blondel B, Chantry AA. Severe adverse maternal and neonatal outcomes according to the planned birth setting being midwife‐led birth centers or obstetric‐led units. Acta Obstet Gynecol Scand. 2024;103(12):2465-2474. doi:10.1111/aogs.14971
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