Mater Research Institute, University of Queensland, South Brisbane, QLD, Australia.
The School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
BJOG. 2018 Jan;125(2):149-158. doi: 10.1111/1471-0528.14903. Epub 2017 Oct 19.
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.
Retrospective cohort study.
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.
A total of 131 436 births during 1998-2013: 69 037 public and 62 399 private.
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.
Stillbirth, and neonatal and perinatal mortality rates.
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.
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.
Private obstetrician-led care: more obstetric intervention and earlier births reduce perinatal mortality.
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 doctor. Method The study population included 131 436 births (52.5% public; 47.5% private) from 1998-2013 at a single metropolitan centre with co-located public and private facilities. To isolate the effect of differences in care, we used a statistical technique called propensity score matching to select a public group and a private group with similar characteristics and equal size. This enabled us to compare 'apples with apples' when comparing public versus private perinatal death rates. Perinatal deaths include stillbirths and babies that die within 28 days of birth. Main findings After matching and after accounting for different patterns in the use of fertility treatments and multiple-birth pregnancies (such as twins), babies born in the public sector were approximately 1.5 times more likely to die than babies born in the private sector. This difference was reduced to 1.3 times more likely to die than babies born in the private sector after taking into account other factors that could skew the data, such as major congenital anomalies, birth method, and duration of pregnancy. Limitations This was a single-centre study, so the results may not apply to all settings. Despite our efforts to create highly similar public and private cohorts, some differences between the groups are likely to have remained and this may have affected the results. Implications Our findings suggest that private obstetrician-led care has a beneficial impact on perinatal deaths, despite, or possibly because of, higher obstetric intervention rates and earlier births in the private hospital. Further research is required.
研究公共和私立医院之间的死产率、新生儿死亡率和围产儿死亡率差异是否是人口特征和/或临床实践差异的结果。
回顾性队列研究。
一个包含公共和私立医院的大都市三级中心。妇女可以选择私人产科医生或公共模式的护理 - 主要是助产士主导的护理或由助产士、全科医生和产科医生共同提供的护理。
共有 131436 例分娩，1998 年至 2013 年：公共 69037 例，私人 62399 例。
使用倾向评分匹配选择具有相似特征的公共和私人队列。然后使用逻辑回归分析探索公共-私人在辅助生殖技术、多胎、主要先天性异常、分娩方式和胎龄使用方面的差异的影响。
死产率、新生儿死亡率和围产儿死亡率。
在控制了产妇和妊娠因素后，公共组的围产儿死亡率高于私人组（调整后的优势比，aOR 1.53；95%置信区间，95%CI 1.29-1.80；死产 aOR 1.56，95%CI 1.26-1.94；新生儿死亡 aOR 1.48，95%CI 1.15-1.89）。在调整了主要先天性异常、分娩方式和胎龄后，这些差异分别减少了 15.7%、20.5%和 19.6%。
公共分娩比私人分娩更常发生围产儿死亡，这种差异不能用人群差异来解释。临床实践中的差异似乎在一定程度上是造成这种情况的原因。我们没有检查临床实践差异对母婴发病率的影响。需要进一步研究。
私人产科医生主导的护理：更多的产科干预和更早的分娩减少围产儿死亡率。
背景 澳大利亚公立医院出生的婴儿往往比私立医院出生的婴儿更容易死亡。我们的目的是确定这种模式是护理方面的公共-私立差异的结果，还是仅仅与两组人群的特征差异有关。在澳大利亚私立医院，私人产科医生几乎总是在妊娠和分娩期间为每位女性提供持续的护理。公立医院提供多种护理选择，通常涉及助产士和/或家庭医生。方法 研究人群包括 1998 年至 2013 年在一个单一的大都市中心的 131436 例分娩（52.5%公共；47.5%私人），这些分娩都在一个公共和私人设施共同设置的单一地点。为了隔离护理差异的影响，我们使用一种称为倾向评分匹配的统计技术来选择具有相似特征和相等大小的公共组和私人组。这使我们能够在比较公共与私人围产儿死亡率时，比较“苹果与苹果”。围产儿死亡包括死产和出生后 28 天内死亡的婴儿。主要发现 在匹配和考虑到生育治疗和多胎妊娠（如双胞胎）使用的不同模式后，公共部门出生的婴儿死亡的可能性大约是私人部门出生的婴儿的 1.5 倍。在考虑了可能影响数据的其他因素（如主要先天性异常、分娩方式和妊娠持续时间）后，这种差异减少到私人部门出生的婴儿死亡的可能性高出 1.3 倍。局限性 这是一项单中心研究，因此结果可能不适用于所有环境。尽管我们努力创建高度相似的公共和私人队列，但两组之间仍可能存在一些差异，这可能会影响结果。影响 我们的研究结果表明，尽管私立医院的产科干预率较高且分娩较早，但私立产科医生主导的护理对围产儿死亡仍有有益的影响。需要进一步研究。
