A true choice of place of birth? Swiss women's access to birth hospitals and birth centers.

While the place of birth plays a crucial role for women's birth experiences, the interest in out-of-hospital births has increased during the Covid-19 pandemic. Related to this, various international policies recommend enabling women to choose where to give birth. We aimed to analyze Swiss women's choice between birth hospitals and birth centers. Employing spatial accessibility analysis, we incorporated four data types: highly disaggregated population data, administrative data, street network data, addresses of birth hospitals and birth centers. 99.8% of Swiss women of childbearing age were included in the analysis (N = 1.896.669). We modelled car travel times from a woman's residence to the nearest birth hospital and birth center. If both birth settings were available within 30 minutes, a woman was considered to have a true choice. Only 58.2% of women had a true choice. This proportion varied considerably across Swiss federal states. The main barrier to a true choice was limited accessibility of birth centers. Median travel time to birth hospitals was 9.8 (M = 12.5), to birth centers 23.9 minutes (M = 28.5). Swiss women are insufficiently empowered to exercise their reproductive autonomy as their choice of place of birth is significantly limited by geographical constraints. It is an ethical and medical imperative to provide women with a true choice. We provide high-resolution insights into the accessibility of birth settings and strong arguments to (re-)examine the need for further birth centers (and birth hospitals) in specific geographical areas. Policy-makers are obligated to improve the accessibility of birth centers to advance women's autonomy and enhance maternal health outcomes after childbirth. The Covid-19 pandemic offers an opportunity to shift policy.

Introduction

Over the past decades, there has been a–sometimes keenly thought–debate about planned place of birth which mostly has been centered around infant and maternal safety, yielding spectrum-spanning opinions on the issue [1-4]. While some argue that planned home birth “has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients” [3, p31] and that “the obstetrician should recommend planned hospital birth” [5], others raise the question whether we, perhaps, need to ask “is hospital birth safe or sustainable for low risk women?” and advocate for a broadening of our understanding of safety “including physical, psychological, social, cultural and spiritual safety” [1, p9/10]. Besides, it appears that various biases (e.g. publication bias, professional bias) hamper production and use of evidence surrounding the risks associated with place of birth for well-informed clinical decision-making [4]. Irrespective of the debate around place of birth, it has to be noted that in response to the Covid-19 pandemic many families have reassessed their birth plans and awareness of and interest in out-of-hospital births (e.g. home birth, birth centers) have increased, catalyzing the use of home-birthing and birth centers [6-9].

Recent empirical evidence from systematic reviews and meta-analyses has demonstrated that risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital and that low-risk women planning a home birth experienced less interventions and less adverse maternal outcomes [10-12]. Lastly, results of a prospective British birthplace study have lent further support to the claim that healthy women with low-risk pregnancies should be offered a choice of birth setting [13]. In light of this evidence, today various policies recommend enabling women to choose where to give birth and improving women’s access to birth centres [14-17]. For example, according to a recent British guideline on intrapartum care, it should be (a) ensured that all birth settings are available to all women in the local or in a neighboring area; (b) explained in an encouraging way to both multiparous and nulliparous women that they can choose any birth setting; (c) advised to low risk nulliparous women that giving birth in a midwife-led unit “is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit” [18, p.1]. These claims were endorsed by the Swiss Association of Midwifes [14].

Although understood differently across various contexts, respect for autonomy is a central principle in medical ethics being instructive for clinical practice and research [19]. Undoubtedly, it mandates being able to make reasoned choices without interference. Being able to exercise reproductive rights and, particularly, to determine how and where to give birth qualifies as reproductive autonomy [20]. Similarly, a concept analysis on autonomy in place of birth emphasized that being capable of choosing place of birth in the absence of coercion is one prerequisite for an autonomous choice [21]. Finally, emphasizing the imperative to enable women to make reasonable choices, a Cochrane review on place of birth has pointed out that women residing in areas where they are not well informed about possible places of birth “may welcome ethically well‐designed trials that would ensure an informed choice” [22, p2]. However, women’s choices of place of birth are limited by, amongst others, geographical distance from home to the preferred birth setting, by the availability of midwives for home births, or by a family’s low economic status rendering the use of birth centers unaffordable.

The corollary is that policy-makers, obstetric care providers, and governmental authorities are obligated to create a supply level that empowers women to have a true choice, which means (besides being well-informed) having reasonable access to all birth settings. Therefore, the purpose of this paper is to analyze geographical constraints to Swiss women’s choice between a birth hospital and a birth center to explore inequalities, to identify underserved areas, and to estimate the proportion of Swiss women having a true choice of place of birth in times of Covid-19. We employed spatial accessibility analysis (SAA) with a focus on car travel time from a woman’s residence to the respective birth settings. Our findings provide valuable insights into how reproductive autonomy of women of childbearing age is limited by insufficient accessibility of birth settings at the time of choice of place of birth.

Methods

Spatial accessibility

One measure of spatial accessibility to healthcare is distance to nearest provider, which is usually measured from a patient’s residence or from the centroid of a spatial raster-cell [23]. Typically, the statistic-based strategies model the spatial separation between places (e.g. birth settings) and people (e.g. women of childbearing age) analyzing distance or time. The underlying aim is to improve accessibility to healthcare.

Swiss setting

In Switzerland, the most common place of birth is the hospital (2017: 98.3% of 85.990 births) [24]. Besides hospitals, women can give birth at home or in birth centers: freestanding, midwife-led, primary care facilities in the public health system which might collaborate with hospitals and private gynecologists (e.g. regarding transfer, consultation), but in which no physicians work. As such, care is entirely performed by midwifes. Their work is based on guidelines for birth centers.

Defining (true) choice of place of birth

The journey time threshold for birth centers and birth hospitals was set at 30 minutes as this represents an acceptable travel time and this cut-off was used in similar research to define reasonable access to birth facilities [16]. For the purpose of this paper, if both the nearest birth hospital and the nearest birth center were accessible within 30 minutes, a woman was considered to have a true choice.

Data

We incorporated data from four different sources: (1) highly disaggregated population data (i.e. 100x100 meters raster-cells) from the Swiss Federal Statistical Office containing information on gender and age group composition of the resident population to spatialize the researched population [25]; (2) administrative data from the Swiss Federal Office of Topography Swisstopo to spatialize communities and federal states [26]; (3) street network data from OpenStreetMap to which traffic-related car travel speeds were assigned; (4) addresses of existing birth hospitals from the Swiss Federal Office of Public Health and of birth centers from the Interest Group of Swiss Birth Centers (as of December 2020) [27, 28]. Apart from (1) which could be utilized through a University license, the remaining databases were open source and did not require any permission. The suitability of these data has been demonstrated in comparable research [29-31].

Spatial accessibility analysis

Using ArcGIS (ESRI, Redlands, CA), we analyzed Swiss women’s access to birth centers and birth hospitals with the variable of interest being car travel time from women’s residence to the respective birth setting for each 100x100 meters population raster-cell in Switzerland (N = 254.278). The analysis was limited to women of childbearing age which the World Health Organization defines as aged 15–49 [32]. Our analysis included 99.8% of Swiss women of childbearing age (N = 1.896.669). For data protection reasons (i.e. rendering the identification of a single person impossible), each raster-cell of the available population data with an actual value in range of”1” to “3” (i.e. less than four persons residing) got assigned the value “3”, which leads to an artificial increase of the overall N. Thus, data preparation required correction of counts for the respective raster-cells.

In SAA, besides the given infrastructure, the estimated value for travel speed is the second key factor. Hence, in addition to the 27 street categories used in OpenStreetMap, we further differentiated streets based on the surrounding population density and on speed limit. Subsequently, streetmap data was transferred into a routing network. The latter was then combined with the disaggregated 100x100 meters population data (i.e. age and gender composition), which allowed analyzing population on a fine spatial resolution. This combination of the routing network and the population data provided evidence on the supply level of birth hospitals and birth centers. In total, 108 birth hospitals and 25 birth centers were included. We employed two approaches to model accessibility, both resting on the nearest center hypothesis (an individual chooses the facility that is closest to its residence) [29, 30].

First, we used a raster-based method [30]. Based on the streetmap data, we calculated the time needed from each raster-cell’s centroid to the 133 facilities, resulting in an overall accessibility matrix. Travel time of each centroid of a raster-cell was assigned to all women of childbearing age residing in the respective raster-cell. Second, we used a vector-based method [30]. Isochronic values were set to determine in which areas women could reach a facility within the acceptable time threshold of 30 minutes [16]. The resulting isochronic areas indicate a reasonable access for women and enabled us to identify areas with (in)sufficient access (Maps 2 and 3). Most importantly, this step revealed areas with a true choice between birth hospitals and birth centers by detecting overlapping isochronic areas, that is both birth settings could be reached within 30 minutes (Map 1). In the corresponding map, we not only illustrated the number of women of childbearing age but weighted them by the relative proportion of births of each age group in the total number of annual births in Switzerland (15–19: 359≙0.430%; 20–24: 5.218≙6.260%; 25–29: 20.206≙24.243%; 30–34: 33.433≙40.113%; 35–39: 22.356≙26.823%; 40–44: 5.350≙6.419%; 45–49: 425≙0.510%) [25], thereby providing a visual representation of estimated births.

Map 1

Geographical areas with true choice of birth setting.

Statistical analysis and visualization

We exported quantitative data of SAA from ArcGIS to SPSS.26 (SPSS Inc., Chicago, IL) and employed descriptive statistical analyses in order to obtain a better understanding of accessibility of birth settings. Results were visualized to better determine spatial and temporal conditions of access to birth settings.

Results

At a national level, 58.2% of women had a true choice between birth hospital and birth center. Overall, birth hospitals’ accessibility was better. Median travel time to birth hospitals was 9.8 minutes, to birth centers 23.9 minutes. Mean travel time to birth hospitals was 12.5 minutes, to birth centers 28.5 minutes (Fig 1). The proportion of women with a true choice, quartiles of travel times to both birth settings, minimum and maximum travel times, and difference between mean travel times are presented in Table 1.

Fig 1

Mean travel times in minutes for both birth settings.

Table 1

Accessibility of birth settings at national and cantonal level.

			Travel times in min.1
			To birth hospitals					To birth centers
	N (women 15–49)	True choice	Min	Q1	Mdn	Q3	Max	Min	Q1	Mdn	Q3	Max	Mean Δ2
Switzerland	1.896.669	58.2%	0.0	5.2	9.8	16.9	148.1	0.0	10.9	23.9	39.8	335.3	16.0
Zurich	354.560	80.0%	0.0	5.2	8.5	12.2	45.9	0.0	10.7	17.7	27.5	51.2	9.9
Bern	219.957	40.7%	0.0	5.0	10.7	19.1	88.6	0.1	16.0	35.9	48.7	133.2	21.8
Lucerne	91.869	70.1%	0.0	7.3	11.4	17.5	91.1	0.3	19.7	25.1	31.5	123.5	12.9
Uri	7.475	0.0%	0.0	4.2	6.6	14.5	96.4	32.3	68.3	71.2	75.9	152.5	62.9
Schwyz	33.699	3.6%	0.0	4.5	9.0	17.6	55.3	24.6	36.8	45.6	64.8	131.0	40.8
Obwald	7.923	54.0%	0.0	6.9	11.3	20.0	59.1	10.8	20.9	27.7	38.0	80.0	15.7
Nidwald	8.654	99.1%	0.0	6.0	10.9	13.6	40.3	0.3	5.7	10.2	12.5	39.0	-0.8
Glarus	8.279	0.0%	0.4	4.9	12.8	16.5	44.8	42.0	50.5	58.1	64.4	105.6	47.9
Zug	27.830	0.0%	0.0	3.8	6.4	11.3	32.4	31.5	42.6	44.2	46.8	71.1	36.7
Fribourg	73.567	60.8%	0.0	11.5	19.7	28.7	73.1	0.1	12.7	25.1	35.8	79.1	4.3
Solothurn	57.417	12.8%	0.0	6.4	11.1	17.8	64.2	14.3	33.3	44.7	54.0	74.6	29.8
Basle-City	44.980	99.9%	0.0	3.2	4.1	5.1	18.7	0.2	2.9	4.1	5.5	19.6	0.0
Basle-Country	58.654	90.8%	0.0	5.2	7.9	14.4	51.8	0.0	6.7	11.4	16.6	58.2	2.5
Schaffhausen	16.783	83.7%	0.0	5.9	8.7	19.9	45.1	0.0	3.9	6.3	20.3	42.0	-1.5
Outer Rhodes	11.063	72.3%	0.0	4.6	12.1	17.0	49.6	4.9	15.8	20.2	30.3	61.2	10.7
Inner Rhodes	3.343	10.2%	0.0	29.2	31.6	34.4	50.7	13.8	32.5	34.1	37.0	53.9	4.3
St. Gall	110.936	49.9%	0.0	6.3	12.8	20.9	53.3	0.0	14.7	29.9	41.0	79.0	13.6
Grisons	40.716	0.0%	0.0	5.4	14.4	24.1	104.8	39.8	58.7	88.5	132.4	335.3	90.7
Argovia	147.649	23.1%	0.0	7.3	12.0	17.1	39.5	5.7	30.9	38.7	44.8	74.1	25.0
Thurgovia	59.223	11.7%	0.0	10.0	16.9	22.8	41.1	8.9	37.8	46.4	54.6	73.7	29.0
Ticino	72.367	50.3%	0.0	4.2	8.4	13.7	148.1	0.1	9.4	29.9	39.3	188.1	17.1
Vaud	189.100	80.5%	0.0	3.9	8.2	16.2	124.3	0.0	6.9	12.4	24.4	136.3	5.7
Valais	74.291	54.8%	0.0	11.4	18.4	26.2	100.2	0.0	13.1	26.5	56.6	175.6	18.6
Neuchâtel	39.539	62.7%	0.1	5.3	11.0	18.0	86.4	0.2	7.5	15.8	35.7	98.8	7.2
Geneva	121.504	98.5%	0.0	3.2	6.1	8.3	28.2	0.4	5.1	7.7	11.2	37.7	2.0
Jura	15.291	47.3%	0.0	6.5	13.7	28.0	113.1	0.2	13.2	40.0	77.2	149.8	27.4
	Map 1		Map 2					Map 3					Map 4

Note. Values were rounded to first decimal point.

1from a woman’s 100m x 100m raster-cell’s center to the respective birth facility

2Δ stands for difference, namely: (mean travel time to birth centers)–(mean travel time to birth hospitals).

True choice of birth setting

While at a national level less than six out of ten women of childbearing age had a true choice, this proportion varied considerably across cantons (Swiss states; Table 1), ranging from four cantons with 90–100% of women with a true choice (Nidwald, Basle-City, Basle-Country, Geneva) to five cantons with less than 5% of women (Uri, Schwyz, Glarus, Zug, Grisons). Map 1 depicts geographical areas in which women had a true choice.

Accessibility of birth hospitals and birth centers

For Switzerland, interquartile range of accessibility of birth hospitals was 11.7 minutes, that is 50% of women of childbearing age had a travel time to the nearest birth hospital between 5.2 and 16.9 minutes (Table 1). Unsurprisingly, the supply level of birth hospitals was very good with 94% of women having reasonable access to a birth hospital within 30.1 minutes. Consequently, variation across cantons was comparatively small. Map 2 depicts accessibility of birth hospitals on a continuum from red to green; yellow indicates the 30 minutes threshold.

Map 2

Accessibility of birth hospitals.

For Switzerland, interquartile range of accessibility of birth centers was 28.9 minutes, that is 50% of women of childbearing age had a travel time to the nearest birth center between 10.9 and 39.8 minutes. The supply level of birth centers was worse than the one of birth hospitals with only 59% of women having a reasonable access to a birth center within 30.2 minutes. Variation across cantons was enormous, ranging from seven cantons in which at least 75% of women of childbearing age had access to a birth hospital in less than 30 minutes (Zurich, Nidwald, Basle-City, Basle-Country, Schaffhausen, Vaud, Geneva) to nine cantons in which at least 75% of women of childbearing age only had access to a birth center in more than 30 minutes (Uri, Schwyz, Glarus, Zug, Solothurn, Inner Rhodes, Grisons, Argovia, Thurgovia). For four cantons, 0% of women had access within less than 30 minutes (Uri, Glarus, Zug, Grisons). Map 3 depicts accessibility of birth centers.

Map 3

Accessibility of birth centers.

Difference between accessibilities of birth settings

For Switzerland, difference between mean travel times of birth settings was 16.0 minutes, with birth centers’ accessibility being worse. Again, this difference varied considerably across cantons, ranging from ten cantons with a difference smaller than 10 minutes (Zurich, Nidwald, Fribourg, Basle-City, Basle-Country, Schaffhausen, Inner Rhodes, Vaud, Neuchâtel, Geneva) to five cantons with a difference bigger than 30 minutes (Uri, Schwyz, Glarus, Zug, Grisons); for women in Grisons (N = 40.716), mean travel time to the next birth center was more than 1.5 hours longer. Map 4 depicts the difference between travel times (birth center–birth hospital); green indicates a difference between -10 and 10 minutes, that is an area where both accessibilities can be considered marginally different; blue indicates better accessibility of birth centers; red of birth hospitals. Fig 1 presents mean differences for Switzerland and cantons and the factor by which travel times to birth hospitals are greater than travel times to birth centers.

Map 4

Difference between travel times.

Discussion

Overall, women of childbearing age in Switzerland are insufficiently empowered to exercise their reproductive autonomy as their choice of place of birth is significantly limited by geographical constraints. SAA revealed that 41.8% (N = 792.807) of women lack reasonable access to both birth settings and therefore do not qualify as having a true choice. This is a grievance for numerous reasons.

First, providing women with a true choice is an ethical imperative that derives from women’s reproductive rights and the corresponding respect for their reproductive autonomy [20, 33]. Second, according to medical guidelines, women should be enabled to have the full range of choice since there are well-described benefits of giving birth in birth centers (e.g. for low-risk women the level of interventions is lower for out-of-hospital births without additional risks for the infant, positive association between birth interventions and long-term childhood illnesses) [18, 34–37]. Third, not being able to choose the preferred birth setting increases the likelihood of a mismatch between maternal preferences for and the actual facility culture, which translates itself into a higher risk for conflicts and disagreements during IP-DM (e.g. regarding interventions, birthing position, examinations). It is known that such conflicts and disagreements are one etiological factor for autonomy-depriving IP-DM and mistreatment of women in childbirth [38, 39]. The latter, in turn, were shown to negatively affect psychological maternal outcomes after childbirth (i.e. improved psychological outcomes when maternal autonomy was respected and IP-DM was adequately shared among the involved parties) [40, 41]. Hence, adhering to the bioethical principle of respect for (reproductive) autonomy has a salutogenetic effect during and after birth. Fourth, empirical evidence indicates that geographical accessibility of place of birth influences women’s choices [42], which means that a proportion of women end up delivering at a place primarily because it was close, but less because it was preferred. In fact, a recent systematic review of women’s preferences in relation to place of birth concluded that policy-makers and service providers shall extend the availability existing services to offer women a choice that enables them to access services which correspond to their needs and preferences [43]. Along similar lines, a recent resurgence in the use of birth centers in the US was attributed to a “mismatch between what the dominant models of care offer and what most women want” [37, p14]. Finally, given the high numbers of parents experiencing their child’s birth, the previous considerations are not only significant at an individual level but also at a public health level.

Over the past years more and more women opened up about instances of mistreatment in childbirth, such as physical or verbal abuse, discrimination, unconsented interventions, loss of autonomy, or informal coercion. The current state of research suggests that mistreatment of women in childbirth occurs regularly and is not limited globally to particular geographical areas [38, 44–47]. Spanning 34 countries, a systematic review from the World Health Organization highlighted that mistreatment can occur at the levels of interpersonal interaction and the facility [44]. In particular, poor rapport between providers and women and a facility’s culture were important determinants of mistreatment. Related to this, a recent nationwide Swiss study revealed that 26.7% of women experienced informal coercion in childbirth (i.e. opposition, intimidation, manipulation) and that the likelihood of experiencing informal coercion was higher (a) for in-hospitals births than for births in birth centers, (b) for women with a higher preference for autonomous decisions, and (c) for births with interventions [46]. Moreover, findings from the US found higher rates of mistreatment in hospital settings than in community birth settings such as birth centers and when women’s and providers’ preferences for care did not match one another [38]. Finally, it has been evidenced that women equally value safety and psychosocial wellbeing during childbirth [48]. Consequently, the place of birth, the facility culture, and the level of alignment of women’s and providers’ preferences play a crucial role for the quality of women’s birth experiences as well as for physical and psychological health outcomes. This mandates to enable women to choose their preferred birth setting.

The main barrier to a true choice of place of birth was the highly limited accessibility of birth centers in some geographical areas. For Switzerland, 20% of women of childbearing age cannot access a birth center in less than 43.6 minutes and 10% cannot in less than 53.0 minutes. For four cantons the minimum travel time to the nearest birth center was more than 30 minutes (Uri, Glarus, Zug, Grisons) which means that not a single woman of childbearing age had a true choice in these cantons. Furthermore, 50% of women of childbearing age living in Grisons faced a travel time of almost 1.5 hours; in Uri of more than 71 minutes, in Glarus of almost 1 hour. These findings indicate underserved areas and geographically determined disparities in accessibility of birth settings. The absence of birth centers (that leads to such poor accessibility) might reinforce the negativity that still surrounds birth centers and midwife-led facilities [49], due to an impeded contact between people’s life worlds and this particular birth setting.

In fact, research has shown that women’s preferences to give birth outside the hospital were often challenged by healthcare professionals, families, and friends and that women needed to actively gather information, if they considered out-of-hospital births [49]. In connection, geographical constraints, opposition in face of a preference for giving birth outside the hospital, and hampered access to information on births in a non-hospital setting represent major barriers to women’s reproductive autonomy and frequently urge women to choose a birth hospital over a birth center. Hence, (still) opting for the latter requires a great extent of confidence to withstand the headwind as well as more resources (e.g. time, financial) to travel to the preferred place of birth and to successfully seek out information. Especially for low-risk nulliparous women who should be advised to give birth in a midwife-led unit such a situation is lamentable [18]. Women should be given a true choice which has to be encouraged by obstetric staff and supported with full, unbiased information [16], even more so during the Covid-19 pandemic when more and more families consider out-of-hospital births. Naturally, women’s choices are determined by cultural and social norms, by what is offered to them, and by availability of birth settings, but, as Jane Sandall puts it in an editorial, “availability of maternity services does not guarantee use if women find services hard to access or that services do not meet their needs.” [50, p547]. The prevailing situation, however, is often one of limited access to birth centers (as indicated by our analysis), frequently contested preferences to give birth outside the hospital, and a lack of access to adequate information [49].

While accessibility of birth hospitals overall was very good, our analysis identified areas where a notable minority of women of childbearing age faced comparably long travel times. For example, 25% of women of childbearing age in Inner Rhodes had a travel time to the nearest birth hospital of at least 34 minutes. This puts both mother and child at a risk, since it was shown that an increase in travel time to birth hospital is associated with a higher likelihood of early and late neonatal deaths and that residing in a so called maternity care desert (i.e. poor access to birth hospitals and certified midwives) is associated with significantly elevated risks of pregnancy-related and pregnancy-associated mortality [51, 52]. Furthermore, longer travel times to birth hospital might be crucial for home births with complications that require timely transfer to a hospital. In these cases, women might feel uncomfortable with considering a home birth and, as a consequence, are less likely to opt for birthing at home. Against this backdrop, our findings provide valuable insights not only with regard to the supply level of birth centers but also of birth hospitals. However, it has to be noted that for both birth hospitals and birth centers we found a striking variation across cantons which can be attributed to differing topographical and infrastructural actualities, but at the same time is caused by the absence or presence, respectively, of birth hospitals and birth centers.

Limitations

Our study has several limitations. We did not include neighboring countries’ birth facilities. However, it is unlikely that women cross national borders for childbirth. Moreover, the Swiss facility landscape is constantly changing and we cannot preclude that facilities were either closed or opened in the meantime. Nevertheless, the lists of birth hospitals and birth centers were up-to-date (December 2020) and provided by respective authorities. Also, for 429 raster-cells (corresponding to 4.944 women) we were not able to calculate travel times due to topological errors of street network data and incompatibility of different data sources. Anyways, our analysis included 99.8% of Swiss women of childbearing age. Furthermore, the nearest center hypothesis underlying our analysis can be mistaken for individuals who might base the evaluations of their surroundings and preferences regarding birth facilities on different aspects than travel distance. Nonetheless, our analysis offers a detailed spatial insight. Finally, due to unavailable data, we exclusively focused on birth centers and birth hospitals and did not include home births and midwife-led units alongside obstetric units. However, the included birth settings account for the great majority of births in Switzerland [24]. It can be assumed that the proportion of women having a true choice between all four birth settings is even smaller. Analyzing all settings, a UK study found that only 4.2% of women had a true choice [16].

Conclusion

Our analysis provides a high-resolution insight into the accessibility of birth hospitals and birth centers for Swiss women to an extent that allows reporting travel times at a 100x100 meters level. This spatial resolution surpasses previous studies on accessibility of birth settings. The results are important for evaluating the current status quo and analyzing developments in the future. Since we did not cover home births and midwife-led units alongside an obstetric unit, accessibility of these birth settings should be examined by future research. Also, future research should investigate (factors affecting) Swiss women’s attitudes and preferences on place of birth in order to more comprehensively determine the need to reshape the maternal healthcare system (based on both geographical accessibility and maternal preferences).

The health system constraints to Swiss women’s reproductive autonomy identified by our analysis are likely to even permeate IP-DM. Not being able to choose the preferred birth setting forces a proportion of women to opt for an unwanted birth setting in which conflicts and disagreements with the obstetric staff during childbirth are more likely to arise. Policy-makers, obstetric care providers, and governmental authorities should seek to improve women’s choice of place of birth. In their 2021 report, the Aspen Health Strategy Group argues that freestanding birth centers “can reduce maternal mortality and morbidity, providing high-quality, patient-centered, accessible care for the vast majority of pregnancies, which are low-risk” and that they are “a cost-effective alternative to hospital deliveries for low-risk births, with a strong evidence base for better outcomes and higher rates of satisfaction” [37, p12/20]. Moreover, the Covid-19 pandemic and its implications for the health system have been apostrophized as a “‘focusing event’, or policy window, which may enable midwives and their advocates to shift policy”[6] and as a “catalyst for more integrated maternity care” [53, p1663]. In light of this, and despite the challenges for a nationwide availability of birth hospitals and birth centers, such as a shortage of midwives or increasing national health care costs, our findings provide unique data and strong arguments to (re-)examine the need for further birth centers (and birth hospitals) in specific geographical areas in Switzerland.

1 May 2022

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Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

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b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. Please include a caption for figures Map 1-4.

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6. We note that Figures Map 1-4 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

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Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

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The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks for allowing me to review your interesting manuscript. The results on accessibility are very interesting and I suspect could be replicated in many other countries. Given the relatively larger number of birth hospitals when compared to birth centres the difference in travel times is not that surprising.

However, choice of place of birth is dependent on many more things other than accessibility based on travelling times. For example, many birth centres (in my own experience) are limited in capacity and will only accept a limited number of bookings each month. Sometimes this is based on the models of care and the number of women each midwife or group of midwives can care for. Do you have any data on capacity of each birth centre and to what extent this may also limit choices?

Reviewer #2: The topic of the article is very interesting, since it is ne topic to be discussed. I support to accept this article because it offers new perspective and novelty of the topic. I would recommend to accept to publish this article.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: David Ellwood

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

17 May 2022

See attached document

(Please note that maps 1-4 were created by the authors themselves (and not obtained from a third-party) and thus are not copyrighted. Therefore, these maps can be published in their current form without any permission or consent from a possible copyright holder (see first comment in responses to reviewers).)

Submitted filename: Responses to reviewers III.docx

Click here for additional data file.

20 Jun 2022

A true choice of place of birth? Swiss women’s access to birth hospitals and birth centers in times of Covid-19

PONE-D-21-14065R1

Dear Dr. Rost,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Florian Fischer

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for addressing all of my previous comments after the initial review. I have no further comments or questions.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Professor David Ellwood

**********

24 Jun 2022

PONE-D-21-14065R1

A true choice of place of birth? Swiss women’s access to birth hospitals and birth centers

Dear Dr. Rost:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Florian Fischer

Academic Editor

PLOS ONE