Outcomes of deliveries by family physicians or obstetricians: a population-based cohort study using an instrumental variable

Background:

Previous research has suggested that obstetric outcomes are similar for deliveries by family physicians and obstetricians, but many of these studies were small, and none of them adjusted for unmeasured selection bias. We compared obstetric outcomes between these provider types using an econometric method designed to adjust for unobserved confounding.

Methods:

We performed a retrospective population-based cohort study of all Canadian (except Quebec) hospital births with delivery by family physicians and obstetricians at more than 20 weeks gestational age, with birth weight greater than 500 g, between Apr. 1, 2006, and Mar. 31, 2009. The primary outcomes were the relative risks of in-hospital perinatal death and a composite of maternal mortality and major morbidity assessed with multivariable logistic regression and instrumental variable–adjusted multivariable regression.

Results:

After exclusions, there were 3600 perinatal deaths and 14 394 cases of maternal morbidity among 799 823 infants and 793 053 mothers at 390 hospitals. For deliveries by family physicians v. obstetricians, the relative risk of perinatal mortality was 0.98 (95% confidence interval [CI] 0.85–1.14) and of maternal morbidity was 0.81 (95% CI 0.70–0.94) according to logistic regression. The respective relative risks were 0.97 (95% CI 0.58–1.64) and 1.13 (95% CI 0.65–1.95) according to instrumental variable methods.

Interpretation:

After adjusting for both observed and unobserved confounders, we found a similar risk of perinatal mortality and adverse maternal outcome for obstetric deliveries by family physicians and obstetricians. Whether there are differences between these groups for other outcomes remains to be seen.Over the past several decades in Canada, obstetric deliveries have increasingly been attended by specialist obstetricians rather than family physicians.¹ Although specialized care is beneficial for high-risk mothers and their infants,^2–4 there are concerns that it might increase risk for women whose deliveries could be safely managed without a specialized approach. Most prior studies have concluded that obstetric outcomes between family physicians and obstetricians are similar, but many of these studies were small, and none of them adjusted for unmeasured factors that might affect both the choice of delivery provider and outcomes.^5–8Obstetric risk is typically divided between providers, with family physicians and obstetricians sharing the lowest-risk patients, obstetricians caring for moderate-risk patients, and sub-specialized perinatologists caring for the highest-risk individuals. Although traditional statistical methods can be used to adjust for observed differences between these groups, they cannot be used to adjust for unobserved differences. For example, the presence of gestational diabetes mellitus is usually noted, but its severity is often not coded in administrative databases. Women with mild diabetes mellitus are usually eligible for delivery by family physicians, but those with severe diabetes (and the attendant increased risk of adverse outcome) are not. There are many prominent examples where traditional analyses of observational data produced results that were subsequently refuted by randomized trials, presumably because of these unmeasured or unknown factors that also affect treatment decisions or outcomes.^4,9–11The instrumental variable method from the field of econometrics is a technique designed to control for unmeasured covariates in regression analyses. Results from instrumental variable–controlled observational analyses of the effect of angiography after myocardial infarction⁹ and of long-acting bronchodilators on asthma control¹² closely approximated those of randomized controlled trials, whereas analyses using traditional statistical methods differed substantially. Instrumental variable analyses of obstetric data have shown that traditional statistical approaches significantly underestimate the mortality benefit of high-volume hospitals for high-risk neonates.⁴ The objective of the current study was to compare perinatal mortality and maternal morbidity and mortality for deliveries by family physicians and obstetricians using instrumental variable methodology.