As a means of addressing the severe shortage of obstetrics and gynecology doctors in Japan, consolidation of obstetrics facilities has been promoted in recent years. However, since consolidation involves the closure of obstetrics departments in some medical institutions, it is likely to cause deterioration in health care access for pregnant women living in areas where consolidation takes place.

This paper analyzed the impact of health care access on the choice of medical institution among pregnant women living in areas where consolidation has taken place. We first examined the impact of geospatial factors from various aspects, such as hospital location, residence area, transportation means, change in distance to the hospital, and change in travel time to the hospital. How geographical restrictions resulting from consolidation affect pregnant women's choice of medical institution was evaluated in comparison with facilities factors. We then examined whether socioeconomic factors affect pregnant women's institution choice.

We classified medical institutions selected by pregnant women into two categories: hospitals continuing to provide obstetrical services after consolidation ("continuing hospitals after consolidation") and other medical institutions. The latter were further classified into three types: general hospitals with neonatal intensive care units (NICUs) ("other general hospitals with NICUs"), other general hospitals ("other general hospitals"), and maternity hospitals and clinics ("maternity hospitals/clinics"). We carried out analyses using a nested logit model.

Analyses revealed that for all types of medical institutions, pregnant women's choice behavior was influenced by not only geospatial factors, but also facilities factors, indicating that a distance-decay effect is not always present. It was also revealed that pregnant women choosing "continuing hospitals after consolidation" attached more importance to objective factors such as comprehensive medical care facilities/functions, whereas pregnant women choosing "other medical institutions" attached more importance to subjective factors (reputation, etc.) and waiting time.

Japan's local medical care systems continue to suffer from a structural crisis. The aim of this study is to analyze the managerial and financial aspects of the Iwate Prefecture Sawauchi and Fujisawa models and the Shimane Prefecture Oki model, which provide examples of advanced local medical care systems in underpopulated agricultural areas.

This study leads us to the following conclusions: First, it is necessary to meet the need for public medical care and, at the same time, to improve the managerial efficiency of that care. To that end, there is a need to create more flexible systems enabling public medical care institutions and government executives to exercise effective leadership, facilitating teamwork among medical, healthcare and social welfare workers and further promoting cooperation and collaboration amongst residents and community organizations.

Second, there is an urgent need to create systems allowing local communities (prefectures, cities, towns and villages) to flexibly share managerial and financial responsibilities amongst themselves in accordance with the circumstances of individual communities, and facilitating cooperation and mutual checking of performance.

Third, in view of the public and non-market nature of medical services in general and local medical care services in particular, national and local governments need to take appropriate financial measures based on an analysis of the background to the financial deficits of public hospitals.

Fourth, management bodies need to be determined based on the choice of related local governments and local residents in accordance with local historical circumstances.

In order to prevent deterioration of the financial condition of public hospitals, the Ministry of Internal Affairs and Communications formulated the Public Hospital Reform Guidelines in 2007. These guidelines urged local governments across Japan to bring public hospitals into financial stability, though the results of this study may indicate the guideline rather precipitates a breakdown of existing medical care systems in agricultural areas.