JOB MARKET PAPER
Low Staffing Levels in the Maternity Wards: Keep Calm and Call the Surgeon. [PDF]
This paper investigates the relationship between workload and choice of treatment in a large but under-studied segment of the healthcare sector – maternity wards. Using detailed microdata on childbirth, I exploit quasi-random assignment of patients who attempt to have a natural delivery to different ratios of patients-to-midwives and compare their likelihood of changing delivery method. I find that women who face a ratio higher than 1.33 are 45% more likely to give birth by cesarean section (C-sections). This effect is larger for patients who were already admitted with a higher risk of C-section, implying that provision of proper and timely care matters more for this type of patients. Because C-sections are faster than vaginal deliveries -in which the patient follows the course of labor-, the medical team may decide to do more C-sections when time constrained. Using civil status as a proxy for bargaining power -assuming single women are on average more likely to be alone-, I find that only single patients are subjected to unnecessary surgery. This provides evidence that high 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)
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.