JOB MARKET PAPER
Low Staffing in the Maternity Wards: Keep Calm and Call the Surgeon. [PDF] (new version!)
This paper examines how workload causally affects the provision of care in a large but understudied segment of the healthcare sector -- maternity wards. I use detailed patient-level administrative data on childbirth, and exploit quasi-random assignment of unscheduled patients to different staffing ratios. Indeed, nature distributes births and associated problems uniformly across time and this is still the case for unscheduled patients attempting to have a vaginal birth. I find that patients who at admission observe a higher ratio of patients-to-midwives are more likely to get a C-section. I provide suggestive evidence of two mechanisms at play behind this increase. First, the raise in workload lowers the quality of care and this leads to more patients needing a C-section. Consistent with this, patients who were admitted with an ex-ante higher risk of C-section are more affected by workload. Second, the raise in C-sections is driven by single women, while married women are largely unaffected by workload. Because C-sections are faster than vaginal deliveries, and single women are -on average- more likely to be alone in the delivery room, the medical team may find optimal to do more C-sections on single patients when time-constrained. This study provides evidence that midwives' workload is yet another factor which triggers physician-induced-demand for C-sections.
- Media briefing EEA-ESEM Geneva 2016 Meeting.
- Awarded Best Paper by Young Researcher at the Italian Health Economics Association-AIES Meeting 2015.
- Giorgio Rota Best Paper Award for Young Researchers by Centro Einaudi and Fondazione CRT (2018)
Productivity Effects of Dengue in Brazil. (with Sonia Bhalotra, Aline Menezes and Rudi Rocha) [PDF]
Although understanding the role of health in driving labor market outcomes is a matter of great importance, it has proven difficult to isolate this effect due to empirical challenges and a lack of compelling sources of identification. We obtain causal estimates of the effect of health on income and welfare dependency through two different channels: a negative health shock (dengue outbreak) and a positive health shock (opening of a health-care facility). To do this, we rely on instrumental variables and difference-in-difference methods, as well as on novel datasets. We find that dengue outbreaks lower the average working hours and income. This effect is particularly high for low-income individuals, but conditional cash transfer programs can insulate them from this shock. On the other hand, the opening of a new health-care facility in a families catchment area rises family per capita income and employment. All together, this evidence suggest that health shocks are an important part of income, poverty and welfare dependency.
Forgetting-by-not-doing: The Case of Surgeons and Cesarean Sections.
The understanding of the drivers behind the positive correlation between providers' volume and better health outcomes is still superficial. The two leading explanatory mechanisms are `learning-by-doing' and `selective referral', and previous studies testing for learning-by-doing have resorted to instrumental variables in order to alleviate issues of reverse causality. By using data from the Italian health care system, where patients are not allowed to choose a physician, I eliminate concerns regarding possible a selective referral bias. This paper investigates whether cesarean-section surgeons who have performed more procedures in the recent past observe an improvement in performance. Using four years of birth certificates data from one large hospital, I find that, for emergent cases, performing one additional procedure reduces the likelihood of neonatal intensive care unit admission by nearly 1.2 percentage points (5.5%) and of being born with a low Apgar Score by about 1.1 percentage points (10%), all else equal. This effect is not present for the case of elective C-sections. These findings should be taken into account as another positive outcome when considering policies of centralization of C-section services.
Work in Progress
Better Together? Bolsa Familia, School Segregation and Learning Outcomes. (with Gabriela Galassi)
The Effects of Cesarean Delivery on Mother's Fertility and Children's Long-term Health. (with Matilde Machado and Chiara Serra)