Working Paper: NBER ID: w24493
Authors: David Card; Alessandra Fenizia; David Silver
Abstract: Cesarean delivery for low-risk pregnancies is generally associated with worse health outcomes for infants and mothers. The interpretation of this correlation, however, is confounded by potential selectivity in the choice of birth mode. We use birth records from California, merged with hospital and emergency department (ED) visits for infants and mothers in the year after birth, to study the causal health effects of cesarean delivery for low-risk first births. Building on McClellan, McNeil, and Newhouse (1994), we use the relative distance from a mother’s home to hospitals with high and low c-section rates as an instrument for c-section. We show that relative distance is a strong predictor of c-section but is orthogonal to many observed risk factors, including birth weight and indicators of prenatal care. Our IV estimates imply that cesarean delivery causes a relatively large increase in ED visits of the infant, mainly due to acute respiratory conditions. We find no significant effects on mothers’ hospitalizations or ED use after birth, or on subsequent fertility, but we find a ripple effect on second birth outcomes arising from the high likelihood of repeat c-section. Offsetting these morbidity effects, we find that delivery at a high c-section hospital leads to a significant reduction in infant mortality, driven by lower death rates for newborns with high rates of pre-determined risk factors.
Keywords: cesarean delivery; health outcomes; low-risk pregnancies; instrumental variable analysis
JEL Codes: I11; J13
Edges that are evidenced by causal inference methods are in orange, and the rest are in light blue.
| Cause | Effect |
|---|---|
| Relative distance from a mother's home to hospitals with high and low cesarean section rates (J19) | Probability of cesarean delivery (C46) |
| Cesarean delivery (J13) | Emergency department (ED) visits for infants (I19) |
| Cesarean delivery (J13) | Hospitalizations or ED use after birth for mothers (I19) |
| Cesarean delivery (J13) | Subsequent fertility (J13) |
| Cesarean delivery (J13) | Second birth outcomes (J13) |
| Delivery at a high cesarean hospital (I11) | Infant mortality (J13) |