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The Health Effects of Cesarean Delivery for Low-Risk First Births


  • David Card
  • Alessandra Fenizia
  • David Silver


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.

Suggested Citation

  • David Card & Alessandra Fenizia & David Silver, 2018. "The Health Effects of Cesarean Delivery for Low-Risk First Births," NBER Working Papers 24493, National Bureau of Economic Research, Inc.
  • Handle: RePEc:nbr:nberwo:24493
    Note: CH HC LS

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    References listed on IDEAS

    1. Walter Beckert & Mette Christensen & Kate Collyer, 2012. "Choice of NHS‐funded Hospital Services in England," Economic Journal, Royal Economic Society, vol. 122(560), pages 400-417, May.
    2. Martin Halla & Harald Mayr & Gerald J. Pruckner & Pilar Garcia-Gomez, 2016. "Cutting Fertility? The Effect of Cesarean Deliveries on Subsequent Fertility and Maternal Labor Supply," Working Papers 2016-14, Faculty of Economics and Statistics, University of Innsbruck.
    3. Victor Chernozhukov & Christian Hansen, 2005. "An IV Model of Quantile Treatment Effects," Econometrica, Econometric Society, vol. 73(1), pages 245-261, January.
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    Cited by:

    1. Depalo, D.;, 2019. "Explaining the causal effect of adherence to medication on cholesterol through the marginal patient," Health, Econometrics and Data Group (HEDG) Working Papers 19/13, HEDG, c/o Department of Economics, University of York.
    2. Amaral Garcia, Sofia & Nardotto, Mattia & Propper, Carol & Valletti, Tommaso, 2019. "Mums Go Online: Is the Internet Changing the Demand for Healthcare?," CEPR Discussion Papers 13625, C.E.P.R. Discussion Papers.
    3. de Elejalde, Ramiro & Giolito, Eugenio, 2019. "More Hospital Choices, More C-Sections: Evidence from Chile," IZA Discussion Papers 12297, Institute of Labor Economics (IZA).
    4. Tonei, Valentina, 2019. "Mother’s mental health after childbirth: Does the delivery method matter?," Journal of Health Economics, Elsevier, vol. 63(C), pages 182-196.
    5. Mireille Jacobson & Maria Kogelnik & Heather Royer, 2020. "Holiday, Just One Day Out of Life: Birth Timing and Post-natal Outcomes," NBER Working Papers 27326, National Bureau of Economic Research, Inc.

    More about this item

    JEL classification:

    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • J13 - Labor and Demographic Economics - - Demographic Economics - - - Fertility; Family Planning; Child Care; Children; Youth

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