>> The reduction in the number of maternity clinics is mainly driven by the personnel and maintenance costs that the clinics cannot cover via the DRG system with fewer than 1,200 births per year6. However, only 238 of the 657 maternity hospitals in Germany achieved this number of births in 2019 (7). The German average in 2017 was 1,134 births per clinic.
However, since 2010, the gap between the clinics in the average number of births per clinic and year has increased significantly. In 2017, the average number of births in the West German states was 1,103 and in the East German states only 807 (8).
When a maternity ward in a clinic is closed, this is usually met with local resistance from communities and especially women. In Mecklenburg-Western Pomerania it affected the hospital in Wolgast in 2016. There were discussions about the maternity wards in the hospital in Bergen in 2018, in the hospital in Demmin in 2019 and currently in the hospital in Crivitz in 2019/20 (9). Every single closure has led to some very emotional discussions, especially recently. In a petition against the closure of the maternity ward in Crivitz, citizens justified their signing by saying, among other things, that “this special maternity ward should be preserved with its popular and caring care” or “because I was born in Crivitz myself” (10).
We at UCEF have taken the recent discussions about maternity clinics as an opportunity to investigate the question of whether increasing birth numbers can reduce the health-economic pressure on maternity clinics.
The number of maternity hospitals has also been significantly reduced in Mecklenburg-Western Pomerania. In 1991 there were 30, then in 2001 only 22; and since 2016 there have only been 16 maternity hospitals in Mecklenburg-Western Pomerania (1). Of these 16 clinics, 4 are Level 1 perinatal clinics, but only 2 of them had more than 1,200 births in 2019. In 2017, the average was 796 births per clinic, although this was not achieved by 11 of the 16 clinics in Mecklenburg-Western Pomerania (7).
Only in the case of a high-risk pregnancy in accordance with the G-BA's Quality Assurance Guideline for Premature and Full-term Babies/QFR-RL should a woman giving birth go to an appropriately equipped clinic in the first three categories. The expectant mothers usually have the choice between the maternity clinic closest to their home or another one that either belongs to one of the first three categories or is more routine due to the large number of births. Or they follow the suggestion of the supervising midwife.
If you look at maternity hospitals from the perspective of proximity, the Voronoi diagram is suitable. Mecklenburg-Western Pomerania is divided into individual regions with the clinics as centers. We then assigned the communities to each region to summarize the desired demographic data.
Figure 1 shows the Voronoi regions (black lines) and the supply regions formed from them by assigning the communities. The colors correspond to the mean annual number of births from 2016 to 2019 according to the Milupa birth lists (7).
In order to compare the births in 2016 and 2017 with the children born in the respective communities, the number of births is provided with correction factors for the proportion of births outside the clinic (2), for multiple births (1) and stillbirths (1). The correction factor of 1.031 (3) live births per birth that we derived from information on this corresponds well with the mean of the ratio of live births to births in the years 2008 to 2017 for Germany of 1.032 (1). Using this correction factor, based on the average number of live births for 2016 and 2017 and the average number of births in the country, one can assume that around 1.2% of the births may be due to women from other federal states, or the assumed proportion of births outside of clinics was too high, multiple births were lower and/or stillbirths were higher. However, for the assigned care areas and their respective maternity hospitals, the comparisons of births with the respective live births were significantly larger, so that there appears to be migration of deliveries between individual regions. This proportion is also likely to be higher than that due to high-risk pregnancies from regions with maternity hospitals to regions with level 1 perinatal centers.
Despite the use of clinics other than the closest ones for births (see Fig. 1), clinics in regions with fewer than 600 births per year are likely to have problems refinancing the necessary personnel and maintenance costs via the DRG system ( 6). This results in health economic pressure to further reduce the number of available maternity wards. These are decisions with a large number of components to be taken into account, the complexity of which cannot be discussed here. We only want to shed light on one aspect here. How will the number of births develop in the next 15 years? Based on forecasts, we would like to clarify whether this can lead to a possible relaxation for the maternity hospitals.
In recent years, in connection with rising birth rates nationwide, attention has been drawn to the increase in the total fertility rate (TFR). This fell to a historic low of around 0.8 in the new federal states at the beginning of the 1990s, only to rise continuously thereafter1. This also applied to Mecklenburg-Western Pomerania and initially led to increasing numbers of newborns (from 9 to 13 thousand). However, since 2000 these have stagnated at around 13 thousand newborns per year (Fig. 2). This in turn results from a significant decrease of more than 130 thousand women of childbearing age between 15 and 44 years. Although this decline has reduced significantly since 2011, the TFR has stagnated at around 1.55 since 2015 (11).
Using a simple model, based on the demographic information on the number of women aged 0 to 44 years in annual cohorts and assumptions about the further development of the TFR, we made forecasts about the development of the number of women of childbearing age and the number of live births for the determined in Mecklenburg-Western Pomerania over the next 15 years.
For the number of women of childbearing age, we determined the average rate of change by year from the last 10 years (2008 - 2017) for each annual cohort and calculated it for the extrapolation of the respective age cohorts from 2017 and 2018. We also randomly selected rates of change from the respective range of an annual transition and applied them to the baseline values for 2017 and 2018 a total of six times.
These numbers for the individual annual cohorts were used to estimate births according to the age structure of the expectant mothers in 2017 and a TFR = 1.55 (stagnating TFR) or an annually continuously increasing TFR from 1.55 to 1.71. This age structure was maintained for all years.
Figure 3 shows the results of the forecasts for both the number of women between the ages of 15 and 44 and the number of children born at a constant TFR as well as at an increasing TFR. At first glance, it may be surprising that despite only a slight decrease in the number of women of childbearing age by 2024, the number of newborns falls particularly sharply in both TFR scenarios. The reason for this lies in the age cohort of women who were born between 1992 and 1996. They formed the cohort of 25- to 29-year-old women in 2021 and the cohort of 30- to 34-year-old women in 2026. According to the 2017 TFR, around a third of women in each of these age groups give birth to a child during this period. However, the cohort of women born from 1992 to 1996 is only half the size of the cohort of women born in the five years before and is also about 20% smaller than the 5-year cohorts of women born afterwards.
The number of newborns in the state of Mecklenburg-Western Pomerania will therefore fall below 11,000 by 2023/24, reach a low point of 9,500 to 10,250 in 2029 to 2031 and then slowly increase slightly again.
The expected number of newborns in Mecklenburg-Western Pomerania will therefore lead to a decline in births by more than 15% in 2023/24 and even by 21 to 26% in 2029/31. Then in the 8 maternity hospitals with the lowest births per year (Fig. 1) there would almost always be less than one birth per day during this period (2023 to 2031). With the current financing of supply and maintenance costs via the DRGs, subsidies would therefore be necessary. Even the closure of one or two maternity clinics would not change anything significantly for the remaining 8 clinics.
If the current financing system is retained, only a reduction to 9 hospitals with maternity wards would ensure reasonably sufficient financing via the DRG system. Then, on average, between 1,000 and 1,200 births per year would take place in these clinics.
A solution for the preservation of a maternity clinic cannot be achieved in individual cases, because this will only postpone the problem in a number of other clinics. There is a need for an overall concept for all maternity hospitals, which in a democracy should be developed with the participation of all those affected, for example in the form of an analytical-deliberative discourse: “It includes two important components: on the one hand, the analytical task, to the best of our knowledge, the possible consequences of different to determine decision options in all their complexity and interconnectedness; on the other hand, the deliberative task of finding an effective, efficient and fair solution to the original problem on the basis of a deliberative discourse” (12). We hope to have made a small contribution to the former. <<

from:
Dr. Günter Jost I and Dr. Thomas Kehl II

I = Independent Center for Empirical Market and Social Research GmbH (UCEF); II = Sanofi

literature
1 Federal health reporting
2 https://www.quag.de/quag/natalnumbers.htm (accessed on June 18, 2020)
3 Quality Assurance Guideline for Premature and Full-term Babies/QFR-RL of the Federal Joint Committee
4 https://perinatalzentren.org/hospitalsuche.php (accessed on June 17, 2020)
5 Press kit from the Federal Association “The Premature Child” eV as of April 1, 2018
6 Prof. Abou-Dakn in an interview with Ärzteblatt 2017; [https://www.aerzteblatt.de/nachrichten/77877/eine-Geburtsklinik-muss...]
7 birth list Germany (various years); Milupa GmbH
8 own calculations based on data from federal health reporting
9 https://www.ostsee-zeitung.de/Nachrichten/MV-aktuell/Schwesig-Schliessung-der-Geburtenstation-Crivitz-falsche-Entscheid (December 10, 2019)
10 https://www.change.org/p/schlie%C3%9Fung-der-geburtsstation-crivitz-stoppen-nicht-noch-ein-weiteres-wolgast-in-mv-manuelaschwesig-asklepiosgruppe?recruiter=673782611&recruited_by_id=9db9e320-e7de-11e6-8c29-3d32292e7c9e&utm_source=share_petition&utm_medium=copylink&utm_campaign=petition_dashboard (abgerufen am 18. 6. 2020)
11 Mecklenburg-Western Pomerania Statistical Office (numbers) and own calculations
12 Renn, Ortwin (2019) “Feeling Truths”, Verlag Barbara Budrich, p. 176.

annotation
This article was based on a lecture during the spring meeting of the UCEF health services research project group in front of actors from various areas of the healthcare system (members and invited guests), held as a video conference in May 2020.