Whoops, they did it again

Regular blog readers might recall that in June last year, Joshua Gans and I released a paper (copy here) on the impact that the sudden introduction of the $3000 Baby Bonus had on births. Because a baby born on 1 July 2004 got $3000, plenty of mothers delayed having their baby until July 2004. We estimated that around 1000 births were moved from June to July 2004. Most of these were moved by just a few days, but some were moved by more than two weeks. Why? Because when everyone wants to book in for a planned c-section on 1 July 2004, the maternity hospitals hit capacity (there were more births on 1 July 2004 than any other day in the last 32 years).

When our study came out, we said that the one thing the government shouldn’t do was to suddenly raise the baby bonus on 1 July 2006. But they did raise it – by $834 – and new daily births data allow us to look at the effects of that. We find (the new study is here) that the new increase led to 600 births being moved from June 2006 to July 2006. It’s hard to know the health impact of this, but changing the timing of births for non-medical reasons can only have adverse health impacts on mothers and babies.

In today’s Sydney Morning Herald, Mal Brough continues a recent tradition of ad hominem attacks by government ministers on university researchers (Andrew Norton, don’t worry, I won’t sue!), saying:

“It’s a good thing that these men chose economics and not obstetrics,” Mr Brough said. “The timing of the birth of a baby is between a woman and her doctor and to suggest that a woman would put the life of her unborn baby at risk to get more money is an insult.”

But of course, many did move births. Is Brough really telling us that it’s merely a crazy coincidence that the #1 birthday in 32 years is the day the Baby Bonus began? And as for our career choice, you don’t have to believe economists. Here’s what the peak obstetricians’ body had to say last June, a few days after our report came out.

A leading obstetrician has called on the Federal Government to bring forward the date of the rise in the baby bonus to reduce the risk of women delaying birth to secure the extra money.

The director of Women’s and Children’s Health Services at the Royal Prince Alfred Hospital, Dr Andrew Child, has approached the Government with his concerns.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has also approached the Government, expressing its concern that mothers and babies could be put at risk by delaying births to cash in on the bonus.

The baby bonus is due to increase from $3166 to $4000 next Saturday.

Dr Child, a past president of the college, calculated it would cost the Government about $5 million to bring the date forward to tomorrow based on figures showing that about 5000 babies were born nationally each week.

“If I were [federal Health Minister] Tony Abbott, I would think very seriously about that,” Dr Child said.

He said $5 million was not much compared with the potential health risks of delaying births.

“One suggestion is bringing it back to June 26. It’s one solution to a potential risk of people waiting too long and putting themselves or their baby at risk.”

Also in June 2006, the President of the Australian Medical Association made a similar recommendation, pointing out: “Whatever date Government puts down for bringing in these sorts of incentives will always bring with it this sort of behaviour” (ABC News, 25/6/06).

The Baby Bonus is due to go up again on 1 July 2008, probably by about $700. If it causes a few hundred births to be moved from June to July, clogging the maternity wards in early-July, it sounds to me as though the current federal government is pretty relaxed about that.

Update: Joshua’s blog has more on the study and the subsequent political reaction.

Media (courtesy of JG):

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22 Responses to Whoops, they did it again

  1. Pingback: CoreEcon » Blog Archive » An Expected Unusual Day

  2. Tanya says:

    “The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has also approached the Government, expressing its concern that mothers and babies could be put at risk by delaying births to cash in on the bonus.”

    So, these data could be used to check that, right? Have these and the previous data been used to examine the effects on mothers and children of shorter an longer pregnancies? The seem like some nifty experimental data … if an IRB was feeling less rabid than is usual and would let researchers join datasets.

  3. Kevin Cox says:

    Given that you want to introduce a baby bonus or perhaps in the future get rid of it then you could make the introduction date some random date in the past. Will this work or are there other implementation solutions that prevent these non desirable effects?

  4. Andrew Leigh says:

    Tanya, we have some charts in our first Baby Bonus paper looking at the effect of the policy on birthweight (answer: more very heavy bubs). What we’d like is to be able to plot mean Apgar scores by day across June and July. Know anyone who’d like to share those data with us?

  5. David Rubie says:

    Andrew, I’m not sure the Apgar test data will tell you much – the method of collection is so, um, diverse as to make the data questionable at best (some wards really, really take their time in doing it for example). It’s used far more as a screen than a serious attempt at gathering information. Better to try to find some data on rises in emergency C-sections or other unplanned interventions. Better yet, try to track the numbers of mothers who planned a C on a particular date but missed it due to baby deciding to come earlier than expected.

  6. Rajat Sood says:

    Really! Isn’t it extraordinary that we cannot trust mothers to do the right thing by the health of their foetuses/babies for the sake of $800 but we then allow these people to Take The Kids Home Afterwards! If you really believed this sort of behaviour constituted a material health risk, wouldn’t you be compelled to licence parents and implant contraceptive devices inside all unlicensed women?

  7. Tanya says:

    David’s comment on Apgar scores is rather scary. Where are the Aussie Atul Gawandes??

    Either way, there are some recent studies on Medline that show use of Australian Apgar scores … meaning that there must be a way to get hold of them. Unfortunately the only thing that I can suggest is that you add a friendly med school researcher to your team to increase the chance of extracting them from hospital bureaucracies. Perhaps with a “more qualified” co-author – especially a grey-haired, paternalistic type – that ding-dong of a minister and his buddies might actually listen.

    Rajat: But, would you trust The Government to design a test of potential parents?? Anyway, licensing of government ministers might be more productive!

  8. Rajat Sood says:

    Tanya, no I woudn’t – which is basically my reductio ad absurdum/floodgates argument for why the government should not cave in to the bringing forward brigade. I am sure lots of people do change their hospital dates to get the extra money, but I strongly doubt that this is compromising the health of their child. And if it, you wouldn’t or shouldn’t trust people to raise their own children.

  9. Steve Edney says:

    I agree with Rajat. While its easy to believe people are changing the dates for the money, there is a 5 week window of what is considered normal full term. (37-42 weeks) and no real reason to think that the variation have any effect on the health of the child.

    For many C sections performed for reasons such as baby being in a breech position etc there is no reason to think that there is any problem with waiting to 41 weeks to have the operation rather than say 40 weeks. Similarly there is as I understand it a several day window in what is considered the appropriate time to induce for a baby going over term. Its easy to see that people have chosen to vary births within these normal bounds.

  10. Andrew Leigh says:

    David, it sounds like you’re merely saying that Apgar scores are measured with error. But so are lots of variables. Measurement error isn’t the same as saying they’re useless. Here’s one study:

    Aim: To estimate the risk of adverse outcomes for newborns with a low Apgar score.
    Study design: Population-based cohort study. All 235,165 children born between 1983 and 1987 in Norway with a birth weight of at least 2500 g and no registered birth defects were followed up from birth to age 8 to 12 years by linkage of 3 national registries. Outcomes were death and cerebral palsy (CP).
    Results: Five-minute Apgar scores of 0 to 3 were recorded for 0.1%, and scores of 4 to 6 were recorded for 0.6% of the children. Compared with children who had 5-minute Apgar scores of 7 to 10, children who had scores of 0 to 3 had a 386-fold increased risk for neonatal death (95% CI: 270-552) and an 81-fold (48-138) increased risk for CP. If Apgar scores at both 1 and 5 minutes were 0 to 3, the risks for neonatal death and CP were increased 642-fold (442-934) and 145-fold (85-248), respectively, compared with scores of 7 to 10.

    Tanya, there are certainly different norms across disciplines about how involved authors need to be in papers. I love this paragraph, for example:

    Contributors: CLR designed the study protocol, analysed the data, and participated in writing the paper; she will act as guarantor for the paper. ST initiated the research and participated in the study design, interpretation of the data, and writing of the paper. BP discussed core ideas, participated in the design of the study, data analysis, and interpretation of the findings, and contributed to the paper. Charles Algert provided advice on data analysis and presentation of the results and commented on the manuscript. David Henderson-Smart commented on the manuscript. Tim Churches and Devon Indig maintain the New South Wales health department’s Health Outcomes Information and Statistical Toolkit data warehouse system.

  11. Lauredhel says:

    Better yet, try to track the numbers of mothers who planned a C on a particular date but missed it due to baby deciding to come earlier than expected.

    While that may be an interesting enough dataset, it doesn’t constitute an adverse event, except in terms of hospital convenience. There is a strong school of thought suggesting that even for planned C sections with a medical indication [1](breech, twins), waiting until labour begins is optimal for infant health.

    Better to look at maternal and infant morbidity and mortality, NICU admissions, difficulty establishing breastfeeding. I’ll draw a fairly short bow here and say you’re likely to see no effect, or possibly a slight _decrease_, since iatrogenic prematurity/near-term birth would drop in the delay-for-the-bonus scenario. Elective C sections and inductions are massively, massively overperformed, and both carry risks.

    Do please let us know if those data become available.

    [1] Though whether these are, in fact, indications is up for debate, that’s a separate issue.

  12. Tanya says:

    Oh. My. That’s almost TMI. Where’s the shroud? Their prose is so clear and concise, it took only five minutes to read the entire paper. What can this mean for The Academy?!

    Seriously, I had held back earlier; was going to suggest that you would just offer co-authorship status in return for only helping to get the data. After all, the RQF fun and games are on their way.

  13. Pingback: CoreEcon » Blog Archive » Baby Bonus on ABC Online

  14. Yobbo says:

    It’s “Oops”.

  15. David Rubie says:

    Andrew Leigh wrote:

    David, it sounds like you’re merely saying that Apgar scores are measured with error.

    Not so much with error, but perhaps not consistent with the baby outcomes. Children with gross respiration issues or whatever don’t have the test done as a rule (child is obviously in trouble, you are not going to be ticking the boxes on your assessment sheet). Children that are obviously well aren’t necessary scored at the same time as other children. There’s obviously a high statistical correlation between really poor scores and really good scores and child outcomes in Denmark, but to assume that’s the case in Australia would be stretching things somewhat. Out of three births in my family, only the middle child had the proper 1 minute apgar done (the first was in a humidi crib within minutes, the third was explaining to the midwives what they did wrong in no uncertain terms). I think I’d do a re-run of the Danish study, but with Australian data, before extrapolating the results of any study trying to connect baby-bonus related birth delays to child health issues.

    As Lara says, over-performed C sections might actually be causing health issues for mums’n’bubs. Instead of worrying about paying baby bonuses, we might be better off paying normal delivery bonuses.

  16. Pingback: Blogger on the Cast Iron Balcony » Blog Archive » Selfish ber-loody women at it again

  17. Andrew Leigh says:

    David, I’d be pleased to replicate the Norwegian study, but it’s hard to imagine how you would do it in a country where people don’t have national ID numbers.

    Yobbo, trust you to be the one correcting me on Britney lyrics.

  18. Pingback: CoreEcon » Blog Archive » Reactions on the baby bonus

  19. Ian Deans says:

    Read the Minister’s comment again: “The timing of the birth of a baby is between a woman and her doctor and to suggest that a woman would put the life of her unborn baby at risk to get more money is an insult.”

    The Minister is not saying that the timing of births was left unaltered; he is saying that mothers did not choose to move the birth date if it posed a risk to the child’s health. Now you can argue for and against the truth of this statement but in the absence of any research, common sense suggests that no, a mother would not deliberately endanger her child for $800.

  20. Andrew Leigh says:

    Ian, I’m not sure it makes much sense to read the Minister’s quote out of context. Even doing so, it’s not clear to me why looking at birth moves and health risks insults mothers. The mother who I know best takes the view that she’d like to see more research on obstetrics risks, not less.

  21. ChrisPer says:

    Not to put too fine a point on it, a mother at full term is not even close to a rational agent.
    I KNOW 99% will always make decisions in line with the best outcome fo rher and the baby. I also have heard a welfare mother with a new (sixth or seventh) baby say that their new van was paid for by the baby.

    I know her well enough to be sure that the best interest of a child comes a long way down her priorities.

    But nearly every mother that allows a pregnancy to continue for the cash, will be getting good advice from her doctor and acting on it. It isn’t an issue, if a few are less scrupulous, because the mother and the doctor are the only ones in a position to make the decision in any case. Is it any worse than caesars and inductions being scheduled for weekdays because the doctor is at work then?

  22. Rajat Sood says:

    Andrew, I’m not sure what you mean by suggesting that Ian was reading the Minister’s quote “out of context”. In what way? Further, Ian was not debating whether researching birth moves is insulting to mothers. He (and I) are simply saying that even if (or just because) birth timing changes as a result of the baby bonus does not imply that the child’s health is likely to be materially affected as a consequence. As ChrisPer says, “Is it any worse than caesars and inductions being scheduled for weekdays because the doctor is at work then?”
    Where I would disagree with ChrisPer is:
    (1) the idea that full-term mothers are irrational agents. For example, most mothers don’t re-start drinking or smoking just prior to giving birth – most wait until at least the baby is born; and
    (2) that even if they are, that this would mean that they become more materialistic – intuition suggests that full-term mothers going nuts due to being heavily pregnant would be more likely to request earlier rather than later delivery than mothers at the outset of pregnancy.

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