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Open Access Research article

The impact on neonatal mortality of shifting childbirth services among levels of hospitals: Taiwan's experience

Shi-Yi Wang12, Sylvia H Hsu3* and Li-Kuei Chen4

Author Affiliations

1 Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware Street, S.E., Minneapolis, MN, 55414, USA

2 Ton-Yen General Hospital, 69 XianZheng 2nd Street, Chu-Pei City, Hsin-Chu County, Taiwan

3 Schulich School of Business, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada

4 Department of Anesthesiology, National Taiwan University Hospital, No.7, Chung-Shan S. Road, Taipei, 100, Taiwan

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BMC Health Services Research 2009, 9:94  doi:10.1186/1472-6963-9-94

Published: 8 June 2009



There is considerable discussion surrounding whether advanced hospitals provide better childbirth care than local community hospitals. This study examines the effect of shifting childbirth services from advanced hospitals (i.e., medical centers and regional hospitals) to local community hospitals (i.e., clinics and district hospitals). The sample population was tracked over a seven-year period, which includes the four months of the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan. During the SARS epidemic, pregnant women avoided using maternity services in advanced hospitals. Concerns have been raised about maintaining the quality of maternity care with increased demands on childbirth services in local community hospitals. In this study, we analyzed the impact of shifting maternity services among hospitals of different levels on neonatal mortality and maternal deaths.


A population-based study was conducted using data from Taiwan's National Health Insurance annual statistics of monthly county neonatal morality rates. Based on a pre-SARS sample from January 1998 to December 2002, we estimated a linear regression model which included "trend," a continuous variable representing the effect of yearly changes, and two binary variables, "month" and "county," controlling for seasonal and county-specific effects. With the estimated coefficients, we obtained predicted neonatal mortality rates for each county-month. We compared the differences between observed mortality rates of the SARS period and predicted rates to examine whether the shifting in maternity services during the SARS epidemic significantly affected neonatal mortality rates.


With an analysis of a total of 1,848 observations between 1998 and 2004, an insignificantly negative mean of standardized predicted errors during the SARS period was found. The result of a sub-sample containing areas with advanced hospitals showed a significant negative mean of standardized predicted errors during the SARS period. These findings indicate that despite increased use of local community hospitals, neonatal mortality during the SARS epidemic did not increase, and even decreased in areas with advanced hospitals.


An increased use of maternity services in local community hospitals occurred during the SARS epidemic in Taiwan. However, we observed no increase in neonatal and maternity mortality associated with these increased demands on local community hospitals.