Perinatal mortality disparities between public care and private obstetrician‐led care: a propensity score analysis

• Published in: BJOG : an international journal of obstetrics and gynaecology 2018-01, Vol.125 (2), p.149-158
• Main Authors: Adams, N, Tudehope, D, Gibbons, KS, Flenady, V
• Format: Article
• Language: English
• Subjects: Adult; Birth; Births; Cohort Studies; Congenital defects; Female; Fertility; Gestational age; Health care delivery; Healthcare Disparities; Hospital sector; Hospitals; Hospitals, Private; Hospitals, Public; Humans; Infant; Infant Mortality; Infant, Newborn; Midwifery; Morbidity; Mortality; neonatal death; Neonates; Obstetrics; Obstetrics - standards; Perinatal Mortality; Population; Population studies; Pregnancy; Pregnancy Complications - mortality; Private medical care; propensity score; Queensland; Reproductive technologies; Reproductive technology; Retrospective Studies; Socioeconomic Factors; Statistical analysis; Stillbirth
• ISSN: 1470-0328; 1471-0528
• DOI: 10.1111/1471-0528.14903

Objective To examine whether disparities in stillbirth, and neonatal and perinatal mortality rates, between public and private hospitals are the result of differences in population characteristics and/or clinical practices. Design Retrospective cohort study. Setting A metropolitan tertiary centre encompassing public and private hospitals. Women accessed care from either a private obstetrician or from public models of care – predominantly midwife‐led care or care shared between midwives, general practitioners, and obstetricians. Population A total of 131 436 births during 1998–2013: 69 037 public and 62 399 private. Methods Propensity score matching was used to select equal‐sized public and private cohorts with similar characteristics. Logistic regression analysis was then used to explore the impact of public–private differences in the use of assisted reproductive technologies, plurality, major congenital anomalies, birth method, and gestational age. Main outcome measures Stillbirth, and neonatal and perinatal mortality rates. Results After controlling for maternal and pregnancy factors, perinatal mortality rates were higher in the public than in the private cohort (adjusted odds ratio, aOR 1.53; 95% confidence interval, 95% CI 1.29–1.80; stillbirth aOR 1.56, 95% CI 1.26–1.94; neonatal death aOR 1.48, 95% CI 1.15–1.89). These disparities reduced by 15.7, 20.5, and 19.6%, respectively, after adjusting for major congenital anomalies, birth method, and gestational age. Conclusions Perinatal mortality occurred more often among public than private births, and this disparity was not explained by population differences. Differences in clinical practices seem to be partly responsible. The impact of differences in clinical practices on maternal and neonatal morbidity was not examined. Further research is required. Tweetable Private obstetrician‐led care: more obstetric intervention and earlier births reduce perinatal mortality. Plain Language Summary Background Babies born in Australian public hospitals tend to die more often than those born in private hospitals. Our aim was to determine whether this pattern is a result of public–private differences in care or merely linked with differences in the characteristics of the two groups. In Australian private hospitals, a private obstetrician almost always provides continuing care to each woman during pregnancy and birth. Public hospitals provide a number of care options, which usually involve midwives and/or a family doc