Changes in Spatial Access to Obstetric Care in Germany from 2014 to 2024: A Nationwide Travel Time Analysis

When a woman goes into labor, time is often the most critical factor. While some births can be planned with precision, the moment a baby decides to arrive is rarely predictable. For the vast majority of pregnancies, the safest path leads to a hospital with a maternity ward, a place equipped with doctors and midwives ready to handle both routine deliveries and unexpected emergencies. The distance to that facility matters. If the drive is too long, the window for a safe, planned arrival narrows, and the risk of giving birth on the side of the road or in a car increases. This is not just a matter of convenience; a longer journey can mean the difference between a smooth delivery and a life-threatening complication for the mother or the newborn. In Germany, health officials have long recognized this reality, setting a specific benchmark: a drive of forty minutes or more to the nearest maternity ward is considered dangerous and should be avoided whenever possible.

Over the last decade, the landscape of childbirth in Germany has shifted dramatically, not because fewer babies are being born, but because the places where they are born are disappearing. Hospitals are closing their maternity wards, a trend driven by a combination of financial pressures, shortages of specialized staff, and a push to centralize care into larger, high-volume centers. The question facing public health experts was simple yet urgent: as these doors close, how much longer are women having to drive to get to a safe place to give birth? A recent study by researchers from the Max Planck Institute for Demographic Research and other institutions set out to map this changing geography of care. They did not rely on estimates or surveys; instead, they calculated the actual driving time for every woman of childbearing age across the entire country, year by year, from 2014 to 2024. By tracing the roads from every square kilometer of Germany to the nearest open maternity ward, they built a precise picture of how access has eroded.

The results reveal a stark transformation. In 2014, there were 745 maternity wards operating across Germany. By 2024, that number had dropped to 573, a loss of 172 wards, or nearly a quarter of the country's total capacity. While the total number of women of reproductive age in the country decreased slightly during this period, the number of women facing a dangerous commute more than doubled. In 2014, roughly 48,000 women lived in areas where the drive to the nearest ward took forty minutes or longer. By 2024, that figure had surged to over 101,000. This means that the proportion of women in this high-risk category nearly doubled, rising from less than three-tenths of one percent to six-tenths of one percent of all women of childbearing age. The study found that this increase was not a slow, steady creep but accelerated noticeably after 2021, with the number of women facing critical travel times climbing sharply in the final years of the decade.

Crucially, the researchers discovered that the problem was not evenly distributed. The closure of most maternity wards had little to no effect on the driving times for the women living nearby, usually because another facility was close enough to pick up the slack. The crisis was driven by a very small number of closures. Just 27 specific ward closures were responsible for more than 90 percent of the new women who suddenly found themselves facing a forty-minute or longer drive. Seven of these closures alone accounted for more than half of the total increase in critical travel times. One single closure in the state of Brandenburg in 2023 instantly pushed 6,298 women into the high-risk category, a number larger than the combined impact of all 159 other closures that had the smallest effect. This pattern suggests that the geography of risk is defined by a few critical gaps rather than a general shortage of facilities.

The impact of these closures is heavily concentrated in specific regions, particularly in the north and east of the country. States like Mecklenburg-Western Pomerania, Brandenburg, and Schleswig-Holstein saw the most dramatic changes, with the proportion of women facing long drives rising significantly. In contrast, the three city-states of Berlin, Bremen, and Hamburg, which are densely populated, experienced almost no closures and saw no increase in travel times. This divergence has widened the gap between regions, creating a map where a woman's safety is increasingly dependent on her postal code. The study measured this inequality using a statistical tool called the Gini coefficient, which tracks how evenly a resource is distributed. The score for travel time inequality rose from 0.303 in 2014 to 0.312 in 2024, a clear signal that the burden of long commutes is becoming more concentrated in specific, often rural, areas.

The authors of the study emphasize that while centralizing care can improve the quality of treatment for high-risk pregnancies, the decision to close a ward must be weighed against the geographic reality of the surrounding area. When a ward closes in a remote location without a nearby alternative, the consequences are immediate and severe. The researchers point out that for women in these affected areas, the only way to maintain safe access might be to change how they approach the final weeks of pregnancy. They suggest that providing temporary housing close to a maternity facility for expectant mothers in their final weeks could be a vital solution, a strategy already used in other countries to reduce the risk of unplanned out-of-hospital births. The study concludes that while the trend of consolidation is likely to continue, future decisions must be made with a clear understanding of the travel times they create. Without targeted support and mitigation strategies, the closure of even a few key maternity wards will continue to push more women into a dangerous zone where the clock is ticking against them.