Comparison between public and private sectors of care and disparities in adverse neonatal outcomes following emergency intrapartum cesarean at term – A retrospective cohort study

Abstract

BackgroundPerinatal outcomes may be influenced by a variety of factors including maternal demographics and medical condition as well as socio-economic status. The evidence for disparities in health outcomes stratified by type of care (public or private) is lacking. The aim of this study was to investigate short term neonatal outcomes following category 1 and 2 emergency cesareans at term between publicly and privately funded women at a single major tertiary centre in Australia. Category 1—immediate threat to life (maternal or fetal); Category 2—maternal or fetal compromise that is not immediately life-threatening.MethodsThis was a retrospective, cross sectional study of 61355 term singleton babies born at the Mater Mother’s Hospital in Brisbane, Australia in 2007–2014. We collected data from the hospital’s maternity database and compared maternal demographics, indications for cesarean and neonatal outcomes for publicly and privately funded women.ResultsOver the study period there were 32477 public and 28878 private, term singleton births. Compared to the publicly funded cohort, privately insured women were older, had lower BMI, were of Caucasian ethnicity, Australian born, nulliparous, had shorter labors and had lower rates of hypertensive disorders and diabetes. The most common indications for category 1 and category 2 cesareans in combination were non-reassuring fetal status followed by failure to progress in labor and malpresentation. For both category 1 and 2 cesareans, neonatal outcomes (Apgar score <7 at 5 minutes, abnormal cord gases, Neonatal Critical Care Unit admission rates, rates of severe respiratory distress and jaundice) were significantly worse in the publicly funded compared to the privately insured cohort Multivariate analyses controlling for maternal age, ethnicity, country of birth, parity, hypertension, diabetes mellitus, gestational age at birth and length of labour confirmed that private insurance status was highly protective for the perinatal outcomes of Apgar score <7 at 5 minutes (aOR 0.26, 95% CI 0.13–0.55), admission to NCCU (OR 0.51, 95% CI 0.30–0.92) and respiratory distress (aOR 0.60, 95% CI 0.41–0.86).ConclusionBirth in the private health sector was inversely associated with adverse neonatal outcomes following category 1 and 2 cesareans.

Determinants of neonatal mortality among neonates admitted to neonatal intensive care unit of Dessie comprehensive and specialized hospital, Northeast Ethiopia; An unmatched case-control study

“…Neonates delivered at public health institutions had three times higher odds of neonatal mortality as compared to neonates who were delivered at private health institutions. This result was in line with the results of the study conducted in Australia ( 36 ). This might be because of the high coverage of birth in public health institutions as compared to private health institutions.…”

Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study

“…In an Australian single centre, retrospective, crosssectional study from 2007 to 2014 of 61,355 singleton term deliveries, neonatal outcomes following emergency CS were worse for women choosing public care rather than private care [19]. The differences in the public deliveries in low Apgar scores at 5 min, admissions to the Neonatal Critical Care and respiratory distress all persisted after multivariable analysis for feto-maternal factors.…”

The profiles of public and private patients in maternal healthcare: a longitudinal study to examine adverse selection

“…Dahlen et al (2014) argued that it was clinicians' behavioural differences that increased private intervention rates, even among lowrisk women, which resulted in other adverse maternal and neonatal outcomes, and ultimately increased costs incurred. Conversely, other studies have found that neonatal outcomes were better in the private system (Robson et al, 2009;Adams et al, 2017Adams et al, , 2018Jang et al, 2017). In particular, Adams et al (2018) control for a vast number of risk factors and conclude that clinical practices may be partly responsible for lower neonatal mortality rates in the private system.…”

“…There are other models of care available in the public system which include the involvement of multidisciplinary obstetric teams if indicated by risk factors or complications (Adams et al, 2018). Public-private comparisons have shown that there are clear disparities in cost risk factors (William et al, 2018b) and clinical services (Roberts et al, 2000;Shorten & Shorten, 2000;Dahlen et al, 2012Dahlen et al, , 2014Einarsdóttir et al, 2012Einarsdóttir et al, , 2013bNippita et al, 2015) with mixed results on how this may impact on neonatal and maternal outcomes (Shorten & Shorten, 2002;Robson et al, 2009;Einarsdóttir et al, 2012Einarsdóttir et al, , 2013aDahlen et al, 2014;Adams et al, 2017Adams et al, , 2018Jang et al, 2017) by system; however, these studies have not investigated the detailed profiles of patients that enter into each system. Furthermore, there have been no studies that directly address the potential for adverse selection in private maternal health services, despite the substantially increased usage of private health insurance (PHI) during childbearing years for women (Australian Prudential Regulatory Authority, 2018).…”