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Financial incentives, timing of births, and infant health: a closer look into the delivery room

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Abstract

As a result of strong financial incentives created by the German parental leave reform on January 1, 2007, some 1000 births have been shifted from the last days of 2006 to the first days of 2007, especially by working mothers. This fact is already described in the literature, yet there is no evidence as to the mechanisms and only scarce evidence regarding the effects on newborn health. I use new data to study the timing of C-sections and the induction of births around the day the reform took effect. I estimate that postponed C-sections and inductions account for nearly 80 % of the pre-reform shortfall and nearly 90 % of the post-reform excess number of births. Despite concerns voiced by doctors before the reform, hardly any evidence can be found for detrimental health effects of those shifts, as measured by changes in gestational age, birth weight, APGAR scores, neonatal mortality, or hospitalization.

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Notes

  1. Bergemann and Riphahn [3] and Kluve and Tamm [12] provide analyses of the effect of the reform on female labor force participation. Spiess and Wrohlich [17] estimate the effect of the reform on household income, and [13] estimate the effect on mothers’ breastfeeding practices.

  2. See e.g., http://www.stern.de/gesundheit/gesundheitsnews/elterngeld-die-verlockung-der-getimten-geburt-576757.html (accessed Jan 10, 2014).

  3. Detailed descriptions of the reform and the press coverage in the weeks before the reform took effect is given, among others, in [14] or [12].

  4. Researchers interested in secondary analyses can apply for access at the AQUA institute. Remote access is granted following a positive decision by the Federal Joint Committee (German: Gemeinsamer Bundesausschuss) and subject to a user fee of 500 euros. Details on data collection, methodology, and data access can be found at https://www.sqg.de/datenservice/sekundaere-datennutzung/index.html. From January 1, 2016, onward, the data will be provided by the newly founded Institute for Quality and Transparency in Health Care (IQTiG).

  5. Of course, the absolute number of shifted births can also be estimated directly by using the absolute count as the dependent variable. The results are very similar, see Table A.1 in the Appendix. Yet to compare birth shifting across subgroups of different sizes, it is more convenient to estimate proportional shifts.

  6. Data on occupation were originally taken from the medical history files of the mother. A literal translation of the answer categories is shown in Appendix B. The validity of these data is admittedly unknown. Data quality of medical variables such as birth weight, gestational age, or APGAR scores have of course been validated (see https://www.sqg.de/ergebnisse/datenvalidierung/index.html for information in German). Occupational coding has not been validated and some misclassification is likely, but note that if we assume misclassification to be random, it will bias results downward in the sense that differences in the effect of the Elterngeld reform across occupational groups are attenuated. In other words, the true differences are probably even larger and our findings provide a lower bound.

  7. I have used the 2006 German Socio-Economic Panel (sample restricted to women aged 18–45) for a rough calculation of women’s annual earnings and potential benefits post reform by occupational status. Average net labor income in low, medium, and high level occupations was 7727, 11,471, and 17,476 euros, respectively. Average potential benefits were 5553, 7278, and 10,812 euros plus additional payments if the father also took parental leave. The German Socio-Economic Panel is described in [20].

  8. The cleanest comparison would be a “control year” with New Year’s Eve also being a Sunday. At present, this is not possible because there are no hospital data before 2006 and the next New Year’s Eve that falls on a Sunday is in 2017. However, it is possible to use data from the German birth records—which have been used by [14, 18] to compare the overall number of births 2006/2007 with 2000/2001 and 1995/1996. This comparison yields a (significant) 6.7 % reduction in the number of births in the last week of December 2006 and a 7.8 % increase in the first week of January 2007. These numbers are similar to the main results reported in Table 2. Thus, the distribution of days does not seem to play a decisive role in explaining those findings.

  9. Looking at daily data reveals that—within our study period—the largest number of C-sections was recorded on January 2, 2007. Actually, this was the single day with 13th-largest number of elective C-sections across the entire period 2006 to 2011. The most popular dates were characterized by repdigits such as 8/8/08.

  10. Note that estimating Eq. (4) with \(T>3\) is problematic as long as we restrict the overall observation window to 28 days before to 28 days after the turn of year. If one includes 4-week dummies at each side of the reform date, these dummies together would pick up the entire cross-year difference between treatment and control year and the diff-in-diff interpretation would no longer be valid. However, I argue that extending the analysis to more than 21 days is not necessary because the idea that mothers try to shift births by more than 3 weeks lacks plausibility.

  11. Analyses of general patterns of hours of birth by method of birth reveal that many elective C-sections are scheduled for 8 in the morning on weekdays and 10 in the morning on weekends.

  12. Actual numbers for 20:00 to 7:59 are shown in Appendix Table A.3.

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  1. Schumpeter School of Business and Economics, University of Wuppertal, Rainer-Gruenter-Str. 21 (FN), 42119, Wuppertal, Germany

    Hendrik Jürges

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Correspondence to Hendrik Jürges.

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I am grateful to two anonymous reviewers, Helmut Farbmacher, seminar participants at MEA, Munich, and participants of the German Health Economics Association (DGGÖ) meeting 2014 for helpful comments.

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Jürges, H. Financial incentives, timing of births, and infant health: a closer look into the delivery room. Eur J Health Econ 18, 195–208 (2017). https://doi.org/10.1007/s10198-016-0766-5

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