Neonatal complications in public and private patients: a retrospective cohort study

Factors promoting or inhibiting normal birth

BACKGROUND

In response to rising rates of medical intervention in birth, there has been increased international interest in promoting normal birth (without induction of labour, epidural/spinal/general anaesthesia, episiotomy, forceps/vacuum, or caesarean section). However, there is limited evidence for how best to achieve increased rates of normal birth. In this study we examined the role of modifiable and non-modifiable factors in experiencing a normal birth using retrospective, self-reported data.

METHODS

Women who gave birth over a four-month period in Queensland, Australia, were invited to complete a questionnaire about their preferences for and experiences of pregnancy, labour, birth, and postnatal care. Responses (N = 5840) were analysed using multiple logistic regression models to identify associations with four aspects of normal birth: onset of labour, use of anaesthesia, mode of birth, and use of episiotomy. The probability of normal birth was then estimated by combining these models.

RESULTS

Overall, 28.7% of women experienced a normal birth. Probability of a normal birth was reduced for women who were primiparous, had a history of caesarean, had a multiple pregnancy, were older, had a more advanced gestational age, experienced pregnancy-related health conditions (gestational diabetes, low-lying placenta, high blood pressure), had continuous electronic fetal monitoring during labour, and knew only some of their care providers for labour and birth. Women had a higher probability of normal birth if they lived outside major metropolitan areas, did not receive private obstetric care, had freedom of movement throughout labour, received continuity of care in labour and birth, did not have an augmented labour, or gave birth in a non-supine position.

CONCLUSIONS

Our findings highlight several relevant modifiable factors including mobility, monitoring, and care provision during labour and birth, for increasing normal birth opportunity. An important step forward in promoting normal birth is increasing awareness of such relationships through patient involvement in informed decision-making and implementation of this evidence in care guidelines.

Public-private differences in short-term neonatal outcomes following birth by prelabour caesarean section at early and full term

BACKGROUND

Prelabour caesarean section (CS) at early term (37⁰ -38⁶  weeks) is associated with higher rates of adverse short-term neonatal outcomes and higher costs than those performed at full term (39⁰ -40⁶  weeks). Prelabour CS is more common in private than in public hospitals in Australia, particularly at early term.

AIMS

To evaluate the impact of hospital sector (public or private) and timing of delivery on short-term neonatal outcomes following prelabour CS at term.

MATERIALS AND METHODS

A retrospective cohort study of 22 954 viable singleton prelabour CS births at term (37⁰ -40⁶  weeks) at a single centre encompassing co-located public and private hospitals during 1998-2013 was undertaken. Propensity score analysis was used to adjust for confounding differences between sectors. The primary outcome was Neonatal Critical Care Unit (NCCU) admission with serious morbidity. Secondary outcomes included respiratory distress, vigorous resuscitation and jaundice.

RESULTS

The private hospital performed prelabour CS at over double the rate of the public hospital (33.7% of all private births vs 14.7% public) and more private than public prelabour CSs occurred at early term (66.8% vs 47.9%). Public babies were more than twice as likely as private babies to require admission to NCCU with serious morbidity (adjusted odds ratio (AOR) 2.54, 95% CI 1.77-3.65) but were less likely to need vigorous resuscitation (AOR 0.53, 95% CI 0.45-0.62). Disparities in outcomes between public and private cohorts were accentuated at full term.

CONCLUSION

Despite early-term prelabour CSs occurring more often in the private hospital, public babies had more adverse outcomes and treatment escalations.

Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia

BACKGROUND

currently, care providers and policy-makers internationally are working to promote normal birth. In Australia, such initiatives are being implemented without any evidence of the prevalence or determinants of normal birth as a multidimensional construct. This study aimed to better understand the determinants of normal birth (defined as without induction of labour, epidural/spinal/general anaesthesia, forceps/vacuum, caesarean birth, or episiotomy) using secondary analyses of data from a population survey of women in Queensland, Australia.

METHODS

women who birthed in Queensland during a two-week period in 2009 were mailed a survey approximately three months after birth. Women (n=772) provided retrospective data on their pregnancy, labour and birth preferences and experiences, socio-demographic characteristics, and reproductive history. A series of logistic regressions were conducted to determine factors associated with having labour, having a vaginal birth, and having a normal birth.

FINDINGS

overall, 81.9% of women had labour, 66.4% had a vaginal birth, and 29.6% had a normal birth. After adjusting for other significant factors, women had significantly higher odds of having labour if they birthed in a public hospital and had a pre-existing preference for a vaginal birth. Of women who had labour, 80.8% had a vaginal birth. Women who had labour had significantly higher odds of having a vaginal birth if they attended antenatal classes, did not have continuous fetal monitoring, felt able to 'take their time' in labour, and had a pre-existing preference for a vaginal birth. Of women who had a vaginal birth, 44.7% had a normal birth. Women who had a vaginal birth had significantly higher odds of having a normal birth if they birthed in a public hospital, birthed outside regular business hours, had mobility in labour, did not have continuous fetal monitoring, and were non-supine during birth.

CONCLUSIONS

these findings provide a strong foundation on which to base resources aimed at increasing informed decision-making for maternity care consumers, providers, and policy-makers alike. Research to evaluate the impact of modifying key clinical practices (e.g., supporting women׳s mobility during labour, facilitating non-supine positioning during birth) on the likelihood of a normal birth is an important next step.

Two practice models in one labor and delivery unit: association with cesarean delivery rates

OBJECTIVE

The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital.

STUDY DESGIN

This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression.

RESULTS

Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88).

CONCLUSION

In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000-2008): a linked data population-based cohort study

OBJECTIVES

To examine the rates of obstetric intervention and associated perinatal mortality and morbidity in the first 28 days among low-risk women giving birth in private and public hospitals in NSW (2000-2008).

DESIGN

Linked data population-based retrospective cohort study involving five data sets.

SETTING

New South Wales, Australia.

PARTICIPANTS

691 738 women giving birth to a singleton baby during the period 2000-2008.

MAIN OUTCOME MEASURES

Rates of neonatal resuscitation, perinatal mortality, neonatal admission following birth and readmission to hospital in the first 28 days of life in public and private obstetric units.

RESULTS

Rates of obstetric intervention among low-risk women were higher in private hospitals, with primiparous women 20% less likely to have a normal vaginal birth compared to the public sector. Neonates born in private hospitals were more likely to be less than 40 weeks; more likely to have some form of resuscitation; less likely to have an Apgar <7 at 5 min. Neonates born in private hospitals to low-risk mothers were more likely to have a morbidity attached to the birth admission and to be readmitted to hospital in the first 28 days for birth trauma (5% vs 3.6%); hypoxia (1.7% vs 1.2%); jaundice (4.8% vs 3%); feeding difficulties (4% vs 2.4%) ; sleep/behavioural issues (0.2% vs 0.1%); respiratory conditions (1.2% vs 0.8%) and circumcision (5.6 vs 0.3%) but they were less likely to be admitted for prophylactic antibiotics (0.2% vs 0.6%) and for socioeconomic circumstances (0.1% vs 0.7%). Rates of perinatal mortality were not statistically different between the two groups.

CONCLUSIONS

For low-risk women, care in a private hospital, which includes higher rates of intervention, appears to be associated with higher rates of morbidity seen in the neonate and no evidence of a reduction in perinatal mortality.

A retrospective cohort study of mode of delivery among public and private patients in an integrated maternity hospital setting

OBJECTIVE

To examine the associations between mode of delivery and public versus privately funded obstetric care within the same hospital setting.

DESIGN

Retrospective cohort study.

SETTING

Urban maternity hospital in Ireland.

POPULATION

A total of 30 053 women with singleton pregnancies who delivered between 2008 and 2011.

METHODS

The study population was divided into those who booked for obstetric care within the public (n=24 574) or private clinics (n=5479). Logistic regression analyses were performed to examine the associations between operative delivery and type of care, adjusting for potential confounding factors.

MAIN OUTCOME MEASURES

Caesarean section (scheduled or emergency), operative vaginal delivery (vacuum or forceps), indication for caesarean section as classified by the operator.

RESULTS

Compared with public patients, private patients were more likely to be delivered by caesarean section (34.4% vs 22.5%, OR 1.81; 95% CI 1.70 to 1.93) or operative vaginal delivery (20.1% vs 16.5%, OR 1.28; 95% CI 1.19 to 1.38). The greatest disparity was for scheduled caesarean sections; differences persisted for nulliparous and parous women after controlling for medical and social differences between the groups (nulliparous 11.9% vs 4.6%, adjusted (adj) OR 1.82; 95% CI 1.49 to 2.24 and parous 26% vs 12.2%, adj OR 2.08; 95% CI 1.86 to 2.32). Scheduled repeat caesarean section accounted for most of the disparity among parous patients. Maternal request per se was an uncommonly reported indication for caesarean section (35 in each group, p<0.000).

CONCLUSIONS

Privately funded obstetric care is associated with higher rates of operative deliveries that are not fully accounted for by medical or obstetric risk differences.