Choice of hospital among women with high-risk pregnancies: The potential negative impact of private insurance

Guidelines recommend high-risk pregnancies be delivered at regional perinatal centers or equivalent hospitals (Level 3/4 hospitals) with high-risk obstetricians, neonatologists and advanced neonatal intensive care units available. This study examines the complex relationships between multiple risk factors and delivery at Level 3/4 hospitals in New York State excluding New York City.

High-risk pregnancies delivered from 1993 to 2002 were identified in the state's hospital discharge database. High risk pregnancy was defined by guidelines from the American College of Obstetricians and Gynecologists, National Institutes of Health and the Hobel pregnancy risk score. Factors investigated included distance from the zipcode of residence and the closest Level 3/4 hospital, age, race/ethnicity, residential poverty and insurance. Risk ratios with 95% confidence intervals were estimated using bivariate and multivariate (log-binomial regression) analysis.

Of approximately 200,000 high-risk deliveries, Medicaid HMOs were associated with the most Level 3/4 deliveries (68.4%) and private fee-for-service insurance the least (51.1%).The association between insurance and hospital selection was modified by age and distance to a level 3/4 hospital (attributable risks ranged from 5% to 27%); it was largest for women living close to a level 3/4 and for younger women. Race/ethnicity and residential poverty did not modify the associations between age, distance, and insurance with hospital choice.

Insurance plays an important role for women with high-risk pregnancies selecting guideline-appropriate hospitals, particularly for young women living near (within two miles) of an appropriate hospital. The study is being expanded to assess variation across perinatal networks to identify strong networks for further study.