It's about time: Cesarean sections and neonatal health

Earlier routine induction of labor-Consequences on mother and child morbidity

A growing number of birth interventions had led to a concern for potential health consequences. This study investigates the consequences of earlier routine labor induction. It exploits a natural experiment caused by the introduction of new Danish obstetric guidelines in 2011. Consequently, routine labor induction was moved forward from 14 to 10-13 days past the expected due date (EDD) and extended antenatal surveillance was introduced from 7 days past the EDD. Using administrative data, I find that affected mothers on average had a 9-11 percentage points (32%-38%) higher risk of being induced the following years. Yet, mother and child short- and medium-term morbidity were largely unaffected.

Caesarean section and respiratory system disorders in newborns

Cesarean section (C-section) delivery is associated with a higher risk of respiratory problems in newborns, particularly if performed electively at 37 weeks. This risk is greater than with spontaneous or induced labor but diminishes as gestation advances. To lower the incidence of respiratory issues in newborns, it is vital to promote natural labor, avoid unnecessary C-sections, and offer thorough prenatal care. Healthcare providers and expectant mothers should assess the risks and benefits of elective C-sections carefully. By advocating for natural labor and reducing unnecessary C-sections, the occurrence of respiratory problems in newborns can be decreased. Adequate prenatal care and monitoring are crucial for identifying and managing potential risk factors for respiratory diseases in newborns. It is crucial for healthcare professionals to educate expectant mothers about the risks of elective C-sections and the advantages of allowing labor to progress naturally. By fostering transparent communication and collaborative decision-making between healthcare providers and pregnant women, well-informed choices can be made that prioritize the health of both the mother and the baby. Furthermore, ongoing research and advancements in medical technology can improve our understanding of how delivery methods affect newborn respiratory health, ultimately leading to better outcomes and care practices in the future.

The effect of birth timing manipulation around carnival on birth indicators in Brazil

This paper studies the patterns and consequences of birth timing manipulation around the carnival holiday in Brazil. We document how births are displaced around carnival and estimate the effect of displacement on birth indicators. We show that there is extensive birth timing manipulation in the form of both anticipation and postponement that results in a net increase in gestational length and reductions in neonatal and early neonatal mortality, driven by postponed births that would otherwise happen through scheduled c-sections. We also find a reduction in birthweight for high-risk births at the bottom of the weight distribution, driven by anticipation. Therefore, restrictions on usual delivery procedures due to the carnival holiday can be both beneficial and detrimental, raising a double-sided issue to be addressed by policymakers.

Cesarean Sections and Family Planning Among Ultra-Orthodox Israeli Jews

The elevated frequency of Cesarean sections (C-sections) in OECD countries not only burdens health systems financially but also heightens the risks for mothers and infants. This study explores the feasibility of reducing C-section rates by examining the Israeli ultra-Orthodox population, noted for its large families and low C-section rates. We analyze birth data from an Israeli hospital, focusing on ultra-Orthodox mothers with husbands who are yeshiva students compared to other mothers. Our findings reveal that all else being equal, mothers married to yeshiva students exhibit a lower likelihood of undergoing a C-section and a higher propensity to seek private medical services to avoid this procedure. This behavior is attributed to their preference for large families and the desire to minimize C-sections, which may restrict the number of possible future pregnancies. These insights underscore the potential effectiveness of initiatives encouraging mothers to opt for vaginal deliveries, thereby reducing healthcare costs and maternal-infant risks.

Fitting in? Physician practice style after forced relocation

OBJECTIVE

This study aims to examine how variation in physicians' treatment decisions for newborn deliveries responds to changes in the hospital-level norms for obstetric clinical decision-making.

DATA SOURCES

All hospital-based births in Florida from 2003 through 2017.

STUDY DESIGN

Difference-in-differences approach is adopted that leverages obstetric unit closures as the source of identifying variation to exogenously shift obstetricians to a new, nearby hospital with different propensities to approach newborn deliveries less intensively.

DATA EXTRACTION

Births attributed to physicians continuously observed 2 years before the closure event and 2 years after the closure event (treatment group physicians) or for identical time periods around a randomly assigned placebo closure date (control group physicians).

PRINCIPAL FINDINGS

All of the physicians meeting our inclusion criteria shifted their births to a new hospital less than 20 miles from the hospital shuttering its obstetric unit. The new hospitals approached newborn births more conservatively, and treatment group physicians sharply became less aggressive in their newborn birth clinical management (e.g., use of C-section). The immediate 11-percentage point (33%) increase in delivering newborns without any procedure behavior change is statistically significant (p value <0.01) and persistent after the closure event; however, the physicians' payer and patient mix are unchanged.

CONCLUSIONS

Obstetric physician behavior change appears highly malleable and sensitive to the practice patterns of other physicians delivering newborns at the same hospital. Incentives and policies that encourage more appropriate clinical care norms hospital-wide could sharply improve physician treatment decisions, with benefits for maternal and infant outcomes.

Maternal mortality in Northeast Brazil 2009-2019: spatial distribution, trend and associated factors

OBJECTIVE

To analyze the spatio-temporal pattern of maternal mortality and associated factors in Northeast Brazil, from 2009 to 2019.

METHODS

This was an ecological study using the joinpoint method for temporal analysis and spatial autocorrelation and scan tests to identify clusters; regression models using the ordinary least squares and geographically weighted regression methods were used to identify factors associated with mortality, considering p-value < 0.05.

RESULTS

Maternal mortality decreased by 1.5% (95%CI; -2.5;-0.5) per year (p-value = 0.009); clusters, of deaths were found, mainly in Piauí and Maranhão, the variables associated with the maternal mortality ratio were Gini Index (β = 105.72; p-value < 0.001), municipal human development index (β = 190.91; p-value = 0.001), per capita income (β = -0.08; p-value = 0.001), Firjan Municipal Development Index-Health (β = -51.28; p-value < 0.001), life expectancy at birth (β = -3.50; p-value < 0.001).

CONCLUSION

There was a reduction in mortality in the period studied, with a concentration of deaths, primarily in Piauí and Maranhão; socioeconomic indicators were associated with higher mortality in the region.

MAIN RESULTS

There was a decrease in maternal mortality in Northeast Brazil, from 2009 to 2019. Deaths were mainly concentrated in the states of Piauí and Maranhão. Five socioeconomic indicators were associated with higher mortality in the region.

IMPLICATIONS FOR SERVICES

In order to maintain the trend of falling maternal mortality in Northeast Brazil, the need exists to reduce social inequalities and expand access to health services, especially within the scope of Primary Care.

PERSPECTIVES

Public policies are needed to expand health services in general as well as comprehensive women's health care in the Brazilian National Health System, especially for women living in contexts of greater social vulnerability.

Trend and risk Factors for Severe Peripartum Maternal morbidity - a population-based Cohort Study

OBJECTIVES

While the rates of maternal mortality in developed countries have remained low in recent years, rates of severe maternal morbidity (SMM) are still increasing in high income countries. As a result, SMM is currently used as a measure of maternity care level. The aim of this study was to investigate the prevalence and risk factors of SMM surrounding childbirth.

METHODS

A nested case-control study was performed between the years 2013-2018. SMM was defined as peripartum hospitalization involving intensive care unit (ICU). A comparison was conducted between parturient with SMM to those without, randomly matched for delivery mode and date of birth in a 1:1 ratio. Multivariable logistic regression models were used to evaluate the independent association between SMM and different maternal and pregnancy characteristics.

RESULTS

During the study period, 96,017 live births took place, of which 144 (1.5 per 1,000 live births-0.15%) involved SMM with ICU admissions. Parturient with SMM were more likely to have a history of 2 or more pregnancy losses (18.2% vs. 8.3%, p = 0.004), deliver preterm (48.9% vs. 8.8%, p < 0.001), and suffer from placenta previa (11.9% vs. 1.5%, p < 0.001), and/or placenta accreta (9.7% vs. 1.5%, p = 0.003). Several significant and independent risk factors for SMM were noted in the multivariable regression models: preterm delivery, history of ≥ 2 pregnancy losses, grand-multiparity, Jewish ethnicity, and abnormal placentation (previa or accreta).

CONCLUSIONS FOR PRACTICE

SMM rates in our cohort were lower than reported in developed countries. An independent association exists between peripartum maternal ICU admissions and several demographic and clinical risk factors, including preterm birth and abnormal placentation.

The effects of a national policy to reduce c-sections in Brazil

In this paper, we assess the effects of a national policy implemented in Brazil to avoid unnecessary cesareans. The policy has a supply-side component that prohibits elective c-sections before the 39th gestational week and a demand-side awareness component. Since the policy is not binding for cases with a strong medical c-section indication, we use births of breech- and transverse-positioned babies as a counterfactual for births of cephalic-positioned babies in a difference-in-differences framework. Our results reveal that the policy decreases the rate of c-sections by 1.6 percentage point, and slightly increases gestational time, birthweight, and first-minute APGAR scores. There is evidence that policy effectiveness is driven by its demand-side component.

C-sections and hospital characteristics: a long term analysis on low-risk deliveries

BACKGROUND

Policymakers aim to reduce C-section (CS) rates, due to well documented overtreatment. However, little is known about how hospital characteristics relate to their c-section rates on low-risk deliveries (CSR-LRD).

METHODS

CSR-LRD were computed using inpatient data from all Portuguese National Health Service hospitals (2002-2011). Linear and Fractional Response Models were estimated to quantify the relationship between CSR-LRD and a set of hospital characteristics: hospital size, type (exclusively obstetrics or not), Neonatal Intensive Care Unit (NICU) availability, obstetrician-to-obstetric bed ratio, and teaching status.

RESULTS

CSR-LRD increased from 11.7% (2002) to 14.1% (2008), declining to 12.5% in 2011. While larger hospitals and hospitals with NICU had higher CSR-LRD rates, teaching status and obstetrician-to-obstetric bed ratio had no significant effect. Adjusted estimates, controlling for those four characteristics, indicate 91% of the variation in the CSR-LRD is left unexplained.

CONCLUSION

Hospital characteristics do not explain variation in CSR-LRD rates. Further studies considering medical practice, financial incentives to hospitals and/or physicians, and patient education are needed.

Cesarean Section and Child Development at 3 Years: A Prospective Cohort Study of First Births in Pennsylvania

OBJECTIVES

The rising cesarean birth rate globally has led to increasing concern about long-term unintended consequences, with particular focus on child neurodevelopmental outcomes. This study investigated the association between cesarean birth and early child neurodevelopment, measured at 3 years of age.

METHODS

This was a large multicenter longitudinal prospective cohort study of first-time mothers and their offspring in Pennsylvania. Mothers completed adapted versions of two measures of child development at 36- months postpartum: the modified Parents' Evaluation of Developmental Status (M-PEDS) and a shortened Ages and Stages Questionnaire (S-ASQ). Logistic regression models were used to assess the association between mode of delivery and delayed child development, controlling for confounding variables.

RESULTS

There were 695 (29.3%) children born by cesarean delivery and 1676 (70.7) born vaginally. Children born by cesarean had increased odds of scoring as developmentally delayed on both measures of child development: the M-PEDS (8.9% cesarean and 5.1% vaginal, adjusted odds ratio [aOR] = 1.58, 95% confidence interval [CI] = 1.11-2.24)) and the S-ASQ (6.3% cesarean and 3.3% vaginal, aOR = 1.66, 95% CI = 1.09-2.54). Additional factors associated with developmental delay were male sex, and the maternal factors of high pre-pregnancy body mass index, thyroid disorder, and diabetes.

CONCLUSION

In this large prospective cohort study of first-time mothers and their offspring, cesarean delivery was found to be associated with an elevated risk of delayed child development at age 3 years. This analysis highlights the importance of continued research to understand the impact of cesarean delivery on child development.

Do breaks from surgery improve the performance of orthopaedic surgeons?

This paper explores whether breaks from surgical practice impact surgeons' performance. Using a large panel of orthopaedic surgeons in England, I estimate the effect of surgeons' breaks, measured by the number of days since their last surgery, on the health outcomes of emergency patients admitted after a hip fracture. To identify a causal effect, I implement a surgeon fixed effects model and exploit the quasi-exogenous variation in breaks from unanticipated emergency hip fracture admissions. Results show that short breaks of four to six days reduce 30-day mortality rates by around six percent relative to no breaks. Notably, short breaks also affect the type of surgery carried out, holding patient characteristics fixed. Overall, these findings show that the organisation of surgeons' activity is a possible determinant of the quality of care provided.

Neighborhoods, networks, and delivery methods

We examine the contribution of information transmission among pregnant women to geographic variation in C-sections in Lombardy, Italy. Defining networks as pregnant women living in the same municipality, we observe that if the incidence of C-sections within the womans network is one standard deviation higher over the 12 months preceding delivery, then her probability of delivering by C-section is 0.007 percentage points (3%) higher. This result is mainly a network effect on Italian women, while it arises from both network and neighborhood effects on foreign women. Both groups respond to additional information, such as the incidence of C-section complications. The selection of pregnant women across hospitals does not uniquely explain our results, which are robust to alternative sample selections and specifications.

The obstetrical dilemma hypothesis: there's life in the old dog yet

The term 'obstetrical dilemma' was coined by Washburn in 1960 to describe the trade-off between selection for a larger birth canal, permitting successful passage of a big-brained human neonate, and the smaller pelvic dimensions required for bipedal locomotion. His suggested solution to these antagonistic pressures was to give birth prematurely, explaining the unusual degree of neurological and physical immaturity, or secondary altriciality, observed in human infants. This proposed trade-off has traditionally been offered as the predominant evolutionary explanation for why human childbirth is so challenging, and inherently risky, compared to that of other primates. This perceived difficulty is likely due to the tight fit of fetal to maternal pelvic dimensions along with the convoluted shape of the birth canal and a comparatively low degree of ligamentous flexibility. Although the ideas combined under the obstetrical dilemma hypothesis originated almost a century ago, they have received renewed attention and empirical scrutiny in the last decade, with some researchers advocating complete rejection of the hypothesis and its assumptions. However, the hypothesis is complex because it presently captures several, mutually non-exclusive ideas: (i) there is an evolutionary trade-off resulting from opposing selection pressures on the pelvis; (ii) selection favouring a narrow pelvis specifically derives from bipedalism; (iii) human neonates are secondarily altricial because they are born relatively immature to ensure that they fit through the maternal bony pelvis; (iv) as a corollary to the asymmetric selection pressure for a spacious birth canal in females, humans evolved pronounced sexual dimorphism of pelvic shape. Recently, the hypothesis has been challenged on both empirical and theoretical grounds. Here, we appraise the original ideas captured under the 'obstetrical dilemma' and their subsequent evolution. We also evaluate complementary and alternative explanations for a tight fetopelvic fit and obstructed labour, including ecological factors related to nutrition and thermoregulation, constraints imposed by the stability of the pelvic floor or by maternal and fetal metabolism, the energetics of bipedalism, and variability in pelvic shape. This reveals that human childbirth is affected by a complex combination of evolutionary, ecological, and biocultural factors, which variably constrain maternal pelvic form and fetal growth. Our review demonstrates that it is unwarranted to reject the obstetrical dilemma hypothesis entirely because several of its fundamental assumptions have not been successfully discounted despite claims to the contrary. As such, the obstetrical dilemma remains a tenable hypothesis that can be used productively to guide evolutionary research.

Caesarean delivery and the use of antidepressants

BACKGROUND

The high ratio of caesarean sections (C-sections) is a major public health issue in the developed world; but its implications on maternal mental health are not well understood.

METHODS

We use individual-level administrative panel data from Hungary between 2010 and 2016 to analyze the relationship between caesarean delivery and antidepressant consumption, an objective indicator of mental health. We focus on low-risk deliveries of mothers without subsequent birth in 3 years, and include around 135 000 observations.

RESULTS

After controlling for medical and socio-economic variables, antidepressant use before delivery is associated with an elevated risk of C-section (adjusted OR = 1.10, 95% CI 1.05-1.14) and C-section is associated with a higher probability of antidepressant use within 1-3 years after delivery (e.g. adjusted OR = 1.21, 95% CI 1.12-1.30, within 3 years after delivery, among mothers without pre-delivery antidepressant consumption). Our data restriction ensures that the results are not driven by a mechanical impact of decreasing fertility on the continuation of antidepressant use after a C-section.

CONCLUSIONS

The results suggest that C-section is associated with worse mental health over the 1- to 3-year horizon after birth. This relationship is particularly important if a caesarean delivery is not necessary due to medical reasons, and physicians as well as expectant mothers should be made aware of the potential mental health implications of the mode of delivery.

Cesarean delivery at term for non-reassuring fetal heart rate tracing: risk factors and predictability

OBJECTIVE

To delineate risk factors for adverse outcomes among those who underwent cesarean delivery (CD) for non-reassuring fetal heart rate tracing (NRFHT) and ascertain whether neonatal or maternal morbidity can be predicted accurately.

METHODS

The Consortium on Safe Labor Database was utilized for this secondary analysis. Inclusion criteria were non-anomalous, singleton gestations between 37.0 and 41.6 weeks who underwent CD for NRFHT. Composite adverse neonatal outcomes (CANO) included Apgar <5 at 5 min, seizures, mechanical ventilation, sepsis, intraventricular hemorrhage, necrotizing enterocolitis or neonatal death. Composite adverse maternal outcomes (CAMO) included endometritis, blood transfusion, wound complication, admission to intensive care unit, thromboembolism, hysterectomy or death. Bivariable analysis and multivariable Poisson regression were used to identify risk factors independently associated with adverse outcomes. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for adverse outcomes.

RESULTS

Of 228,438 births in the database, 7310 individuals (3.7%) met inclusion criteria. Among this cohort, CANO occurred 3.8% of the time. CANO was less common among people over 35 years (9.8% versus 18.4% p < .01) but was more common among those with at least high-school education (15.3% versus 11.2%; p < .01), varying by ethnicity (p < .01). CAMO occurred in 3.4% and was less common among those undergoing induction of labor (37.3% versus 49.4%; p < .01) and more common among those with clinical chorioamnionitis (8.4% versus 4.3%; p < .01). The area under the curve (AUC) for ROC curve to identify CANO was 0.63 implying a limited ability to predict neonatal adverse outcomes. The AUC for identifying women with maternal adverse outcomes was 0.69 also indicating a moderate prediction ability.

CONCLUSIONS

Among singletons between 37 and 41 weeks who labored, the rate of CD for NRFHT was about 3.7% and among them CANO occurred in 3.8%. While risk factors for adverse neonatal outcomes following CD for NRFHT are identifiable, they do not suffice to predict them.

Fee equalization and appropriate health care

Fee equalization in health care brings under a unique tariff several medical treatments, coded under different Diagnosis Related Groups (DRGs). The aim is to improve healthcare quality and efficiency by discouraging unnecessary, but better-paid, treatments. We evaluate its effectiveness on childbirth procedures to reduce overuse of c-sections by equalizing the DRGs for vaginal and cesarean deliveries. Using data from Italy and a difference-in-differences approach, we show that setting an equal fee decreased c-sections by 2.6%. This improved the appropriateness of medical decisions, with more low-risk mothers delivering naturally and no significant changes in the incidence of complications for vaginal deliveries. Our analysis supports the effectiveness of fee equalization in avoiding c-sections, but highlights the marginal role of financial incentives in driving c-section overuse. The observed drop was only temporary and in about a year the use of c-sections went back to the initial level. We found a greater reduction in lower quality, more capacity-constrained hospitals. Moreover, the effect is driven by districts where the availability of Ob-Gyn specialists is higher and where women are predominant in the gender composition of Ob-Gyn specialists.

A retrospective review of clinical and non-clinical factors associated with unscheduled cesarean deliveries at one urban medical center

OBJECTIVE

To investigate factors associated with unscheduled cesarean delivery at one urban tertiary medical center.

METHODS

A retrospective chart review was performed on 11 162 deliveries between 2009 and 2019. The dependent variable was unscheduled cesarean delivery. Covariates examined included time of delivery, as well as several maternal and pregnancy-related factors.

RESULTS

There were a total of 7037 (63.1%) vaginal, 1133 (10.1%) elective cesarean, and 2992 (26.8%) unscheduled cesarean deliveries. Independent factors associated with increased odds for unscheduled cesarean delivery included daytime delivery (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.42, P < 0.001); advanced maternal age (OR 1.40, 95% CI 1.26-1.56, P < 0.001); obesity (OR 1.04, 95% CI 1.03-1.05, P < 0.001); history of previous cesarean delivery (OR 2.77, 95% CI 1.91-4.01, P < 0.001); hypertension (OR 1.72, 95% CI 1.27-2.32, P < 0.001); multiparity (OR 3.99, 95% CI 2.82-5.64, P < 0.001); pre-eclampsia (OR 1.96, 95% CI 1.33-2.89, P = 0.001); and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome (OR 5.45, 95% CI 1.13-26.28, P = 0.035).

CONCLUSION

Factors associated with unscheduled cesarean delivery in this study cohort included daytime delivery, advanced maternal age, obesity, hypertension, previous cesarean delivery, multiparity, preterm labor, pre-eclampsia, and HELLP syndrome.

Parental unemployment during the Great Recession and childhood adiposity

The incidence of adiposity in the early years of life has outgrown the prevalence in older children and adolescents globally; however, the factors influencing weight gain are predominantly studied in adults. This study examines the relationship between changing economic conditions during the Irish recession and child weight in a nationally representative sample of 10,011 Irish children studied at 9 months, 3 years and 5 years old. This study is the first to use longitudinal anthropometric measurements to estimate the impact of direct parental unemployment on children's weight. Fixed effect logistic regression is used to examine the effects of parental unemployment on weight using the Growing up in Ireland infant cohort from 2008 to 2013. Weight and length/height measured by trained interviewers and child growth charts are used to quantify children's weight status according to BMI-for-age and weight-for-age measures. For BMI-for-age, the probability of a child being classified as overweight/obese is 8 percentage points higher if either parent experiences unemployment. A sensitivity analysis of weight-for-age indicates that the probability is of similar magnitude across several alternative growth charts and definitions of adiposity (the WHO standard, British Growth Reference, and Centers for Disease Control). The analysis is repeated, cross-sectionally, for physical activity and diet to clarify mechanisms of effect. The probability of a child consuming healthy food and physical activity with an implied cost is lower if either parent becomes unemployed. A focus on overweight/obesity in the early years is of crucial importance as if current trends are not addressed, a generation of children may grow up with a higher level of chronic disease.

A demand-smoothing incentive for cesarean deliveries

We study the demand-smoothing incentives for private hospitals to perform c-sections. First, we show that a policy change in Chile that increased delivery at private hospitals by reducing the out-of-pocket cost for women with public insurance increased the probability of a c-section by 8.6 percentage points despite private hospitals receiving the same price for a vaginal or cesarean delivery. Second, to understand hospitals' incentives to perform c-sections, we present a model of hospital decisions about the mode of delivery without price incentives. The model predicts that, because c-sections can be scheduled, a higher c-section rate increases total deliveries, compensating the forgone higher margin of vaginal deliveries. Finally, we provide evidence consistent with the demand-smoothing mechanism: hospitals with higher c-section rates are more likely to reschedule deliveries when they expect a high-demand week.

The effect of budget cuts on C-section rates and birth outcomes: Evidence from Spain

Using data from Spain, we show the impact of significant health-sector budget cuts introduced in 2012 on the rates of cesarean sections and on infant health outcomes at birth, which we use as a proxy for the quality of birth centers. Exploiting a difference-in-differences fixed-effects approach at the hospital level, we estimate a 3% increase in C-sections as a result of the budget restrictions, with no significant consequences on health outcomes at birth. Given the additional evidence in the literature on the negative short- and long-term effects of non-medically indicated C-sections, our paper provides important policy implications for population health.

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We show the impact of significant budget cuts in the health sector.

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The outcomes we focus on are the rate of c-sections and infant health at birth.

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We estimate a 3% increase in cesarean sections as a result of the budgetary cuts.

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We find no significant consequences on health outcomes at birth.

The strange case of less C-sections: Hospital ownership, market concentration, and DRG-tariff regulation

We evaluate the relationship between hospital ownership and responses to a policy providing large financial incentives for vaginal deliveries and financial disincentives for C-sections. We compare for-profit, nonprofit, and public hospitals operating in a public health care system organized according to the quasi-market model. We first theoretically show that hospital ownership matters insofar different hospitals are characterized by different ethical preferences. We also show that competition makes ownership less important. We then consider the case study of Lombardy in Italy. We exploit spatial variation in hospital ownership and in market concentration at the local level to evaluate the relationship between ownership and the probability of C-section. According to theory, empirical results strongly suggest that competitive pressures from alternative providers tend to homogenize behaviors. However, in local monopolies, in presence of a strong monetary incentive toward vaginal deliveries, we do observe less C-section from private for-profit hospitals than from public and private nonprofit hospitals, especially when C-sections are medically appropriate.

Cutting fertility? Effects of cesarean deliveries on subsequent fertility and maternal labor supply

Despite the growing incidence of cesarean deliveries (CDs), procedure costs and benefits continue to be controversially discussed. In this study, we identify the effects of CDs on subsequent fertility and maternal labor supply by exploiting the fact that obstetricians are less likely to undertake CDs on weekends and public holidays and have a greater incentive to perform them on Fridays and days preceding public holidays. To do so, we adopt high-quality administrative data from Austria. Women giving birth on different days of the week are pre-treatment observationally identical. Our instrumental variable estimates show that a non-planned CD at parity 0 decreases lifecycle fertility by almost 13.6%. This reduction in fertility translates into a temporary increase in maternal employment.

The connection between microbiome and schizophrenia

There has been an accumulation of knowledge about the human microbiome, some detailed investigations of the gastrointestinal microbiota and its functions, and the highlighting of complex interactions between the gut, the gut microbiota, and the central nervous system. That assumes the involvement of the microbiome in the pathogenesis of various CNS diseases, including schizophrenia. Given this information and the fact, that the gut microbiota is sensitive to internal and environmental influences, we have speculated that among the factors that influence the formation and composition of gut microbiota during life, possible key elements in the schizophrenia development chain are hidden where gut microbiota is a linking component. This article aims to describe and understand the developmental relationships between intestinal microbiota and the risk of developing schizophrenia.

Nonclinical predictors of caesarean section: a path analytic approach

The objective of this study was to explore nonclinical predictors of cesarean sections (CS) and how they interact with each other, specifically in Turkey. Data was gathered from official statistical records for the year 2017 from the 81 different provinces throughout Turkey. A path analytic model was constructed to examine the interrelationships between socioeconomic factors, utilization of health services, patient satisfaction, and number of CS procedures. The overall performance of the final path model was quite good (GFI = 0.98, AGFI = 0.93, and CFI = 0.96). The study results emphasize the substantial impact of an increase in the number of hospital admissions on the increase in the rate of CS procedures (PC = 0.70). Additionally, the increase in the number of hospital admissions mediates the interrelationship between geographic region, high education, and CS. The findings demonstrate the significant interrelationships among the several major nonclinical predictors of CS in Turkey.Impact StatementWhat is already known on this subject? There has been a considerable increase in the rate of CS in Turkey and the current study examined the nonclinical predictors of CS, and how they interact with each other, specifically in Turkey. The insights developed by this study are due to its scope and topicality. Although of course clinical factors associated with CS are reflected in the literature, this study focused on nonclinical predictors of CS.What the results of this study add? This study empirically clarifies the causal interrelationships among nonclinical predictors of CS, using data from Turkey where CS rates are very high, causing great concern by health professionals and decision-makers. The results of this study provide a stronger understanding of how nonclinical factors relate to CS in Turkey. Significant factors include the connective role of geographic region, the increasingly high level of education being received by women, and the total number of hospital admissions.What the implications are of these findings for clinical practice and/or further research? Study results empirically prove interconnection among geographic region, education, health services utilisation and the number of CS. Health decision makers need to consider the important indirect effects of region, education and number of hospital admissions on the demand for CS procedures.

Mother's mental health after childbirth: Does the delivery method matter?

The dramatic increase in the utilization of caesarean section has raised concerns on its impact on public expenditure and health. While the financial costs associated with this surgical procedure are well recognized, less is known on the intangible health costs borne by mothers and their families. We contribute to the debate by investigating the effect of unplanned caesarean deliveries on mothers' mental health in the first nine months after the delivery. Differently from previous studies, we account for the unobserved heterogeneity due to the fact that mothers who give birth through an unplanned caesarean delivery may be different than mothers who give birth with a natural delivery. Identification is achieved exploiting exogenous variation in the position of the baby in the womb at the time of delivery while controlling for hospital unobserved factors. We find that mothers having an unplanned caesarean section are at higher risk of developing postnatal depression and this result is robust to alternative specifications.