Adachi et al. Health Economics Review 2013, 3:31 http://www.healtheconomicsreview.com/content/3/1/31 RESEARCH Open Access Impact of specialization in gynecology and obstetrics departments on pregnant women’s choice of maternity institutions Yoshimi Adachi1*, Hiroyasu Iso1, Junyi Shen2, Kanami Ban3, On Fukui4, Hiroyuki Hashimoto5, Takako Nakashima6, Kenichiro Morishige7 and Tatuyoshi Saijo8 Abstract In April 2008, specialization in gynecology and obstetrics departments was introduced in the Sennan area of Osaka prefecture in Japan that aimed at solving the problems of regional provisions of obstetrics services (e.g., shortage of obstetricians, overworking of obstetricians, and provision of specialist maternity services for high-risk pregnancies). Under this specialization, the gynecology and obstetrics departments in two city hospitals were combined and reconstructed into two centers, i.e., the gynecological care center in Kaizuka City Hospital and the prenatal care center in Izumisano City Hospital. This paper investigates to what extent and how this specialization affected pregnant women’s choices of the prenatal care center and other maternity institutions. We used birth certificate data of 15,927 newborns from the Sennan area between April 1, 2007 and March 30, 2010, for Before and After Analysis to examine changes in pregnant women’s choices of maternity institutions before and after the specialization was instituted. Our results indicated that this specialization scheme was, to some extent, successful on the basis of providing maternity services for high-risk pregnancies at the prenatal care center (i.e., Izumisano City Hospital) and having created a positive effect by pregnant women to other facilities in the nearby area. Keywords: Specialization; Gynecology and obstetrics departments; Maternity facilities; Before and after analysis Background City Hospital were merged into the Mother and Child In the Sennan area (i.e., Southern area) of Osaka Prefecture Medical Center. Then, this center was reconstructed in Japan, gynecology and obstetrics departments of two into two new sub-centers. One was called the gynecological small- to- medium-sized hospitals had been closed, and the care center, which is operated by Kaizuka City Hospital. shortage of physicians in gynecology and obstetrics depart- The other center, called the prenatal care center, is operated ments had become a serious problem. The work burdens by Izumisano City Hospital because this hospital has on remaining physicians in that area had been increasing the neonatal intensive care unit and is located close to (i.e., the number of patients seen, the number of shifts the accident and emergency center. Because of this on call, and the number of hours worked), and they specialization, the pregnant women who were examined found it increasingly difficult to provide highly-specialized in Kaizuka City Hospital would move to Izumisano City medical care. Hospital when risk of complication in birth became high In April 2008, a specialization in gynecology and ob- or when they started having contractions, while pregnant stetrics departments was conducted in the Sennan area. women who had been examined in Izumisano City Under this specialization, the gynecology and obstetrics Hospital would remain at the same hospital. departments in Kaizuka City Hospital and Izumisano This specialization in gynecology and obstetrics depart- ments which aimed at solving the problems of regional pro- visions of obstetrics services (e.g., shortage of obstetricians * Correspondence: [email protected] and maternity services for high-risk pregnancies, and over 1Public Health, Social and Environmental Medicine, Graduate School of working of obstetricians) has three main advantages. First, Medicine, Osaka University, 2-2 Yamadaoka, Suita, 565-0871, Osaka, Japan Full list of author information is available at the end of the article each hospital can concentrate on providing the core care ©2013 Adachi et al.; licensee Springer. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Adachi et al. Health Economics Review 2013, 3:31 Page 2 of 11 http://www.healtheconomicsreview.com/content/3/1/31 services within its specialization by completely utilizing the kinds of factors affecting pregnant women’schoice its existing facilities. Second, this specialization enables of maternity facilities and created a database for further the provision of more advanced medical services. Third, studies.Onthebasisofthedatacollectedin[1],the since the physicians from Kaizuka City Hospital are also authors of [2] implemented Cost-Benefit Analysis of the involved in after-hour care at Izumisano City Hospital, specialization for gynecology and obstetrics departments the problem of overworked gynecologists and obstetri- in Kaizuka City Hospital and Izumisano City Hospital. By cians in both hospitals will be mitigated to some extent estimating consumers’ benefits and calculating producers’ by the adoption of a two-physicians-on-duty system. surplus and costs, they reported that the benefit-cost ratio In Japan, because of the shortage of gynecologists and was estimated at 1.367 under a basic scenario, indicating obstetricians, some hospitals often closed gynecology that the specialization can generate a net benefit. and obstetrics departments in one hospital to maintain Several related studies have discussed the factors behind those in another hospital. patients’ choice of hospital. One study examined the im- The specialization undertaken in the Sennan area can pact of waiting and travel times on the choice of cataract be regarded as a new approach in Japan because it would patients in the United Kingdom [3]. That study found that prevent the closure of gynecology and obstetrics depart- travel time had a stronger effect on the choice of hospital ments in either hospital. This specialization enables the than did waiting time [4] and [5] reported that patients prenatal care center of one hospital to provide more ad- responded to not only convenience but also quality and vanced maternity services for high-risk pregnancies, and reputation when choosing fertility clinics for assisted re- the gynecology center of the other hospital to provide productive therapies. more advanced gynecological services. Meanwhile, this In addition, several studies examined issues regarding specialization is considered to have a possible positive changes in hospital organization, such as mergers and effect on other maternity facilities since it allows them closures. Among these studies, three examined the effects the opportunity to attract low-risk pregnancies. In this of hospital mergers in terms of cost and management evaluation of the specialization, we investigated the [6] investigated the outcomes of hospital financial perfor- following research questions. mances before and after physician integration strategies were executed between hospitals. The result indicated that 1) Was the specialization undertaken by gynecology a hospital merger led to cost savings and financial benefits. and obstetrics departments a valid approach to However, the robustness of financial benefits in terms of improve the regional provisions of obstetrical service hospital size and organization has since been debated [7] in the Sennan area? conducted a six-year longitudinal assessment of change 2) Did the specialization of gynecology and obstetrics before and after a merger. In that study, the short-term departments in Kaizuka City Hospital and Izumisano impact of a merger was generally modest, but the impact City Hospital affect pregnant women’s choices? of mergers between similarly-sized hospitals reflected More specifically, we investigated whether the greater efficiency than mergers between dissimilar-sized specialization would bring an effect on pregnant hospitals [8] analyzed the costs and prices of approximately women choosing other maternity facilities, either 3,500 short-term general hospitals from 1986 to 1994. The positive or negative. hospital mergers produced average cost savings of approxi- mately 5%. These savings were generally greater for mergers The remainder of the paper is organized as follows. In between similarly-sized hospitals, and the post-merger price the next session, we provide the detailed reviews on related reductions were smaller in less competitive markets than in studies. Section 3 presents the methodology issues. Results competitive ones. These studies showed that depending and discussions are given in Sections 4 and 5, respectively. upon their scale, hospital mergers led to different levels of Finally, Section 6 draws the conclusions. efficiency. Other studies asserted the need to understand not only the primary motivation of hospitals but also Related studies the overall status of hospitals prior to a merger [9] found To the best of our knowledge, except for the above men- it that a hospital merger would lead to different levels of tioned specialization such a specialization that prevents efficiency depending upon hospital location, because some the closure of any gynecology and obstetrics department hospitals were pressured by their local competitors to in- in either hospital has not been conducted in Japan and crease management efficiency [10] investigated the pre- other countries. Therefore, we are unable to