BB Bounce

Thanks to Peter Martin, some of my research on the Baby Bonus has resurfaced in the press over recent days. Joshua Gans has more.

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29 Responses to BB Bounce

  1. hc says:

    Is this a joke? An increase in the baby bonus from $4187 to $5000 on July 1 will lead to babies being ‘overcooked’ (apparently your term) – i.e. their births being delayed. Therefore you criticise the increase on health grounds!

    The empirics here seem implausible. How many? How much weight gain? How much health costs? In fact there is a suggestion of heightened mortality but no evidence which does not surprise. How much would payment of the increased bonus contribute to greater health by facilitating improved parental investment in ‘child quality’.

    My guess the net policy cost in this direction is negligible.

    From Becker’s Treatise on Family we have known that reducing the cost of having children will increase births. This has happened. Surely if you wanted to assess a pro-natalist policy this would be the basis for doing so.

    I favour a pro-natalist policy because I have a preference for kids being borne locally. You could argue against that position on various grounds but not on the basis of the claim that the health of kids is worsened by a very marginal increment to the bonus.

  2. Andrew Leigh says:

    Harry, the latest version of the paper is here. We don’t deal in our paper with the general issue of whether the BB is good policy – merely the particular issue of whether it’s wise to suddenly increase it. Since the cost of a phased increase is trivial, the health benefit of not moving 700-1000 births need only be tiny to make it worthwhile.

  3. Lara says:

    Andrew, you’re still completely missing the point that these births weren’t “moved” for the baby bonus, they were NOT moved, or moved less than they may otherwise have been.

    Your examination of the medical evidence is too shallow to even be called “superficial”. You take one tiny, out-of-context piece of data from a single paper, then build an entire house of straw around it. You don’t even have a working syllogism in the paper: there are giant, gaping holes in your line of reasoning.

    Your paper is lacking in rigour, based on faulty assumptions and a lack of evidence, illogical, and unscientific. Any continued defence of it after the logic holes have been pointed out to you displays a lack of intellectual honesty.

    Did you have anyone trained in medicine & obstetrics and the scientific method look it over before self-publishing?

  4. Andrew Leigh says:

    Lara, if you have any substantive points to make (as opposed to ad hominem ones), feel free to do so. I have been responding to a few substantive issues raised by a ‘laurelhed’ on Joshua’s blog. I’m not sure if this is you commenting under a different pseudonym.

    And the answer to your final question is yes, we did.

  5. lauredhel says:

    Same me. There was an old id in cookies here. (I’d appreciate it if you’d change my above posts to “lauredhel” for consistency.)

    You haven’t answered to the substantive points, and they’re the same points I made to you last year in this blog, which you didn’t respond to at that time. Again, your argument is based on the assumption that reducing birthweights artificially by delivering babies before spontaneous labour should reduce morbidity and mortality; and it is also based on a false belief that all or the vast majority of obstetric interventions (inductions and scheduled C sections) are medically necessary.

    The early inductions and sections are the births being “moved”, not the less-interfered-with births that occured just after baby bonus cutoff. Your frame is backwards.

    What evidence have you that artifically producing lower birthweights by moving births earlier via induction and C section should reduce morbidity or mortality? Even with _known_ macrosomia, there is no benefit to earlier delivery. A ten minute Medline search got me these:

    What contradictory evidence have you? Is it substantial and replicated?

    Were any births “moved” past 42 weeks around the cutoff? Were they appropriately monitored with biophysical profiles, were safe expectant management protocols followed? Was there ANY change in morbidity or mortality around that time?

  6. lauredhel says:

    Ah, I see you have posted one more response there, an assertion that all these interventions are medically necessary.

    No, they’re not. The WHO has said that a “medically necessary” C section rate likely falls between around 10 and 15 percent. It is lower than that in some northern European countries, with no fall-off in obstetric complications. A 34% rate is completely unjustifiable. Though some obstetricians are holdouts, and think “nothing good happens after 38 weeks” and “vaginal bypass for all!”, there is growing and significant unrest in the obstetric and general community about skyrocketing intervention rates.

    It has taken a lot of pushing just to get obstetricians to keep their hands off scheduled C sections until 39 weeks, to reduce the incidence of iatrogenic prematurity (and even these babies are being born up to 3 weeks earlier than they would be otherwise).

    I’m not coming from a position of ignorance in this, nor am I getting my information or opinions from the mainstream medai. I have degrees in medicine and medical anthropology, and over a decade of experience in medical practice with a specific interest in women’s health.

    For more background:

    Western Australian birth statistics.

    Skyrocketing caesarian section rate means placenta accreta is no longer just the fine print

  7. lauredhel says:

    “with no fall-off in obstetric complications. ”

    (No ‘edit’ button!” this should be “increase”, of course.)

  8. christine says:

    HC has a preference for kids being borne locally, but the BB only pays if they’re born locally doesn’t it?

    (Sorry, I know it was just a typo, I know I should resist, but I couldn’t.)

  9. conrad says:

    Just out of interest Lauredhel — why is there such an increase? I believe it is pretty much a worldwide phenomena, including places with the lowest death rates in the world (like Singapore & HK), where I believe it isn’t nearly as easy to sue your doctor, unlike Aus or the US, so the obvious reason (it happens to avoid litigation) is ruled out.

  10. lauredhel says:

    conrad: that is an enormous topic, and one that I don’t think it’s appropriate to address in detail in comments here. Very briefly, there is a confluence of factors (any one alone would be insufficient, and they are inter-related), including: the institution of medicine taking control of birthing and women’s bodies, technology that allows most women to come out alive from surgical delivery, a set of cultural beliefs around all vaginal birth being “messy” and “uncivilised” and “torture”, a set of cultural beliefs around surgery being “clean” and “quick” and “easy” and “painless”, legal issues (which are about what is likely to meet with acceptance in a court of law, not about what is actually safer), non-rational assessment of relative risks when the risks differ in nature, a multitude of false ideas about birthing mechanics, and now, an acceleration based on the unsupported idea that “once a caesarean, always a caesarean”.

    If you’d like to discuss further, my commentariat would be happy to discuss with you. I can open up comments on an old thread, just drop me a line.

  11. hc says:

    Christine, Not sure the point you are making. I favour the BB. I prefer children borne to residents than immigrants as a source of population growth. And before some fruitcake misrepresents my position – no I am not opposed to immigration – I just have a preference.

  12. Peter Whiteford says:

    I think that lots of issues are getting thrown together here which leads to confusion.

    To Andrew and Joshua, as I read Laura’s comments what she is saying is that Australia has excess Ceasarian sections, and most of these are due to births being induced too early. As I understand it, the substance of your argument is that births are in danger of being delayed in order that parents can qualify for the higher rate of baby bonus.

    These two positions are in direct contradiction of each other.

    Now sometimes births are overdue, but my understanding is that this is more likely to lead to chemical interventions rather than Ceasarians. Again my understanding is that premature births have much higher risks for children than over-term births although these do have risks.

    This appears to me to be an empirical question – so you or Laura should be able to come with the evidence to support your positions.

    On the policy side , I agree that the previous Treasurer may have got over-excited about the fertility impact of the baby bonus. But as has been pointed out in other places, we have the baby bonus as an alternative to some form of paid maternity leave,

    So if you want to to give a comprehensive perspective on this issue, I think that you need to address the question of whether we Australia should have paid maternity leave, and the arguments for and against.

  13. Andrew Leigh says:

    Laurelhed, let’s be clear about what’s happening here. The introduction effect isn’t leading to a drop-off in c-section and inducement rates. In fact, those rates are higher. It’s just that they’re being timed for July (when the BB is higher) rather than June. The only way the bizarre June/July effect can be good for babies is if doctors are systematically timing their c-sections and inducements 1-3 weeks too early. And I have to say, that isn’t something you see written down in Williams Obstetrics.

    PW, on high birthweight, you’ll want to look at p28. Also, our research is only looking at the effect of sudden increases in the BB, so I’m pretty confident that maternity leave is irrelevant.

  14. lauredhel says:

    The only way the bizarre June/July effect can be good for babies is if doctors are systematically timing their c-sections and inducements 1-3 weeks too early.

    Which, as I have said, is exactly what they are doing. Any non-emergency C section done before the onset of labour and before 42 weeks is being done early; and scheduled C sections are typically done at 38-39 weeks (which can be as early as 37 weeks, as the most accurate dating methods available can’t get closer than a week either way.)

    Some data for you to consider. These are extremely crude data; they don’t examine things like near-term babies having more difficulty establishing breastfeeding, for example. And please go re-read my data on macrosomia; I note that you haven’t responded to that.

    “Elective induction: an analysis of economic and health consequences”

    “By use of baseline estimates, induction at any gestational age, regardless of parity and cervical ripeness, required expenditures from the medical system. Although never cost saving, inductions were less expensive at later gestational ages, for multiparous patients, and for those women with a favorable cervix. Sensitivity analysis demonstrated a robust model. CONCLUSIONS: Elective induction of labor at term is not cost saving and results in a large excess of cesarean deliveries. Costs are significantly altered by the timing of the induction, parity, and cervical ripeness.”

    “Respiratory dysfunction in infants born by elective cesarean section without labor”

    “Of the 1486 infants delivered by ECS over the study period 57 (3.8%) developed TTN (50 infants) or RDS (7 infants). The incidence of respiratory dysfunction was inversely related to gestational age, 13.8% at 37 weeks gestation and 2.5% at 40 weeks gestation. A statistically significant reduction in the incidence of TTN or RDS was observed from 38 weeks to 39 weeks gestation (6.6% and 2.3% respectively; p<0.001). There has been a reduction in the incidence of ECS before 39 weeks gestation since 2001, when guidelines regarding optimal timing of ECS were set at our hospital. CONCLUSION: The incidence of respiratory dysfunction in neonates born by ECS is inversely related to gestational age, even in the term infant. It is important to delay ECS until 39 weeks gestation whenever possible, in order to minimize the risk of respiratory dysfunction in the newborn infant.”

    “Admission of term infants to neonatal intensive care: a population-based study.”
    [Australian data}

    “We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks’ gestation. RESULTS: The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low-risk primiparas at 37 weeks’ gestation were 12.08 (99% CI 8.64-16.89); at 38 weeks, 7.49 (99% CI 5.54-10.11); and at 39 weeks, 2.80 (99% CI 2.02-3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks’ gestation. Among low-risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks’ gestation were 15.40 (99% CI 12.87-18.43); at 38 weeks, 12.13 (99% CI 10.37-14.19); and at 39 weeks, 5.09 (99% CI 4.31-6.00). At 41 weeks’ gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47-0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks’ gestation. CONCLUSIONS: The adjusted odds of admission to neonatal intensive care for babies of low-risk women were increased after birth at 37 weeks’ gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures.”

    “Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study”

    “2687 infants were delivered by elective caesarean section. Compared with newborns intended for vaginal delivery, an increased risk of respiratory morbidity was found for infants delivered by elective caesarean section at 37 weeks’ gestation (odds ratio 3.9, 95% confidence interval 2.4 to 6.5), 38 weeks’ gestation (3.0, 2.1 to 4.3), and 39 weeks’ gestation (1.9, 1.2 to 3.0). The increased risks of serious respiratory morbidity showed the same pattern but with higher odds ratios: a fivefold increase was found at 37 weeks (5.0, 1.6 to16.0). These results remained essentially unchanged after exclusion of pregnancies complicated by diabetes, pre-eclampsia, and intrauterine growth retardation, or by breech presentation.

    Conclusion Compared with newborns delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of overall and serious respiratory morbidity. The relative risk increased with decreasing gestational age.”

    “The influence of timing of elective cesarean section on neonatal resuscitation risk.”

    “In the period of weeks 37(+0) to 38(+6), positive pressure ventilation resuscitation risk and single laryngeal mask airway and tracheal tube resuscitation maneuver risk were significantly greatly increased (OR, 4.25; CI, 1.46-16.12; p < .01; OR, 2.25; CI, 1.46-6.12; p < .01; and OR, 11.3; CI, 2.15-16.0; p < .01, respectively). After 38(+6) weeks, there was no significant difference in positive pressure ventilation resuscitation risk. CONCLUSIONS: Elective cesarean section at term, in an obstetric population without prenatally identified risk factors, remains associated with increased resuscitation risk with related implications for the neonate compared with vaginal delivery. A significant reduction in neonatal resuscitation risk would be obtained by waiting until week 39(+0) before performing elective cesarean section.”

    Can you point me to the data showing that delaying birth intervention by 1-3 weeks produced an increase in induction rates? I’m struggling to come up with any plausible mechanism for that.

    Again, you have no evidence that any harm was done, and a small amount of evidence showing that no harm was done. I’d like, at least, for it to be openly state that this was purely a hypothesis-generating paper, not a paper with any data in it.

  15. Andrew Leigh says:

    Laurelhed, I never said you couldn’t find studies in which outcomes were worse under early elective c-sections. But all those you cite are plagued by selection bias. Here’s one that isn’t.

    A growing number of women are requesting delivery by elective cesarean section without an accepted “medical indication,” and physicians are uncertain how to respond. This trend is due in part to the general perception that cesarean delivery is much safer now than in the past and to the recognition that most studies looking at the risks of cesarean section may have been biased, as women with medical or obstetric problems were more likely to have been selected for an elective cesarean section. Thus, the occurrence of poor maternal or neonatal outcomes may have been due to the problem necessitating the cesarean delivery rather than to the procedure itself. The only way to avoid this selection bias is to conduct a trial in which women would be randomly assigned to undergo a planned cesarean section or a planned vaginal birth. When this was done in the international randomized Term Breech Trial involving 2088 women with a singleton fetus in breech presentation at term, the risk of perinatal or neonatal death or of serious neonatal morbidity was significantly lower in the planned cesarean group, with no significant increase in the risk of maternal death or serious maternal morbidity.1

    In response to the growing demand from women to have a planned elective cesarean section, the American College of Obstetricians and Gynecologists published a committee opinion 2 that states

    If taken in a vacuum, the principle of patient autonomy would lend support to the permissibility of elective cesarean delivery in a normal pregnancy, after adequate informed consent. To ensure that the patient’s consent is, in fact, informed, the physician should explore the patient’s concerns. … If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.

  16. lauredhel says:

    Leigh, that’s the Term Breech Trial. The babies were all breech presentations. What do you think it shows, within the context of this discussion?

  17. Andrew Leigh says:

    As you can see from the quote, the American College certainly seems to regard it as evidence that elective c-sections are not more dangerous than vaginal births. And I don’t see anything in their statement suggesting that c-sections are systematically carried out too early.

    And it’s Andrew, unless you’ve suddenly gone all private school on me.

  18. lauredhel says:

    The Term Breech Trial is not evidence that planned C sections across the board are safer than low-intervention vaginal deliveries! Do you think it is scientifically reasonable to extrapolate breech data to vertex presentations? Read the URL you have quoted:

    “What are the risks of cesarean delivery? The maternal mortality is higher than that associated with vaginal birth (5.9 for elective cesarean delivery v. 18.2 for emergency cesarean v. 2.1 for vaginal birth, per 100 000 completed pregnancies in the United Kingdom during 1994–1996).3Cesarean section also requires a longer recovery time, and operative complications such as lacerations and bleeding may occur, at rates varying from 6% for elective cesarean to 15% for emergency cesarean.1,4 Having a cesarean delivery increases the risk of major bleeding in a subsequent pregnancy because of placenta previa (5.2 per 1000 live births) and placental abruption (11.5 per 1000 live births).5 Among term babies, the risk of neonatal respiratory distress necessitating oxygen therapy is higher if delivery is by cesarean (35.5 with a prelabour cesarean v. 12.2 with a cesarean during labour v. 5.3 with vaginal delivery, per 1000 live births).6 Also, a recent study has reported that the risk of unexplained stillbirth in a second pregnancy is somewhat increased if the first birth was by cesarean rather than by vaginal delivery (1.2 per 1000 v. 0.5 per 1000).”

    On that page, the American College, a very-high-intervention-promoting organisation, is supporting “elective” (meaning “voluntary, no medical indication” in this context) C section on the grounds of _patient autonomy_, not on the grounds of safety. As they might look at breast implants or large-volume liposuction. Looking more closely at the issue of “maternal request” C section, which is largely an obstetrician-and-media-produced distraction, shows it to be a small influence, plus one that is very difficult to extricate from clever obstetric manipulation and coercion, and of course distorted societal pressures around birthing.

    Further reading on that: here and here and here. US data:

    The first national data from women themselves clarify that demand from women for a planned initial (or “primary”) cesarean with no medical reason is infinitesimal. Despite some professional and mass media discourse about “maternal request” or “patient demand” cesarean when there is no medical indication, just one woman (0.08%) among 1314 survey participants who might have initiated a planned primary cesarean without medical reason did so. Just that one woman (0.4%) out of 252 survey participants who actually had a primary cesarean initiated a planned cesarean without medical reason. Two other women with a primary cesarean said that it was scheduled ahead of time without medical reason and initiated by a health professional. All others (98% of women with primary cesareans) believed that there was a medical reason for their cesarean. The most common reasons cited were concerns about fetal distress, position of baby, size of baby, and prolonged labor.

    Conspicuously absent in the College’s respect for “maternal request” for C section is a similar attitude to maternal request for no interventions, no analgesia, vaginal birth after C section, vaginal breech delivery, and vaginal delivery of multiple fetuses.

    The Term Breech Trial itself had some major methodological issues, dealt with elsewhere, and that I won’t go into detail on here as it is unrelated to my core thesis. They did not compare C section to physiological birth, and they did not consider the effects on future pregnancies.

    The American College, of course, come from a very particular birthing culture and carry a substantial financial conflict of interest, and this also needs to be borne in mind when considering their opinions.

    There is certainly no reason to privilege their enmeshed opinions over the World Health Organisation.

    And it’s Andrew, unless you’ve suddenly gone all private school on me.

    Nope – posting before coffee, and was just talking with someone named Leigh.

    Also repeating this:

    Can you point me to the data showing that delaying birth intervention by 1-3 weeks produced an increase in induction rates? I’m struggling to come up with any plausible mechanism for that.

    Again, you have no evidence that any harm was done, and a small amount of evidence showing that no harm was done. I’d like, at least, for it to be openly state that this was purely a hypothesis-generating paper, not a paper with any data in it.

  19. Andrew Leigh says:

    Laurelhed, I don’t think we’re likely to get any further in this discussion. Your point is that there are several studies suggesting that c-sections are dangerous, and a couple that suggest that early inducement can be dangerous. My point is that these studies are plagued by selection bias, and there are other studies suggesting that c-sections are not dangerous.

    Your view that c-sections and inducements are carried out 1-3 weeks too early is clearly not a consensus position in the medical literature, or it would have found its way into major texts and official positions of the main obstetrics bodies.

    In any case, you must be quite happy about Roxon’s decision. Carrying your logic through, I assume you’re expecting an improvement in infant health in early-July 2008?

  20. lauredhel says:

    In any case, you must be quite happy about Roxon’s decision.

    Not at all. I think there may be a strong argument to be made phase the introduction in, in our current obstetric climate, purely from a hospital staffing point of view.

    I would like to see birthing intervention to be evidence-based year round, not just tweaked slightly in difficult-to-assess ways for one or two weeks a year.

  21. tigtog says:

    My point is that these studies are plagued by selection bias, and there are other studies suggesting that c-sections are not dangerous.

    The study on which you are most relying is plagued by far worse selection bias than any of the studies Lauredhel cited: the only births included where birth was at full term and the foetus presented for labour in a breech position. Breech presentations make up slightly less than 3% of births, and are uniformly regarded as more complicated and dangerous births than the normal cephalic/vertex position, as Lauredhel attempted to point out to you twice above only to be ignored.

    Extrapolating data generally from a study which only examined breech births seems highly likely to be compromised by confounding data, don’t you think?

  22. Andrew Leigh says:

    Tigtog, what you describe isn’t selection bias – at least, not in the econometric sense. You’re right that the Term Breech Trial focused on breech babies. But so far as I’m aware, it’s the only randomised evidence on c-sections that we currently have, which is why the American College puts so much weight on it.

  23. lauredhel says:

    Andrew, you are still being extremely selective in your choice of bits of evidence. Your dodging of that critique by pompously insisting on purely econometric definitions in an argument about biology is bizarre. If you want to stick to economics, by all means stick to economics.

    Have you read this?

    “Five years to the term breech trial: the rise and fall of a randomized controlled trial.”
    Am J Obstet Gynecol. 2006 Jan;194(1):20-5.
    Glezerman M.

    OBJECTIVE: On the basis of the end points of neonatal morbidity and death, the authors of the term breech trial concluded unequivocally that cesarean delivery was safer for breech babies.

    STUDY DESIGN: Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large interinstitutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise.

    RESULTS: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies.

    CONCLUSION: The original term breech trial recommendations should be withdrawn.

  24. tigtog says:

    what you describe isn’t selection bias – at least, not in the econometric sense

    My hypothesis that economists don’t really understand statistics gains another supporting datapoint.

    You can’t overcome initial selection bias by post hoc randomisation- such studies will tell you a lot about the biased sample group, but will have no valid extrapolation to the general population. That’s why pharmaceutical companies no longer run drug trials only on fit young male college students like they used to: the number of unpredicted adverse reactions, including deaths, became more than merely embarrassing, it was downright profit-threatening.

    The author of the Term Breech Study herself understands this and expresses reservations in her conclusions:

    Unfortunately, for women not having a breech birth, such as those pregnant with twins, women who have had a previous cesarean section, older women, those who are having their first baby, those with incontinence problems and women who are afraid of labour, we have little information on the true benefits and risks of planned elective cesarean section compared with planned vaginal birth.

  25. Mark Picton says:

    Whilst the health/ welfare conclusions in the paper are more careful than those in the newspaper article, some discussion of the second-best question is probably a good idea.

    The only way the bizarre June/July effect can be good for babies is if doctors are systematically timing their c-sections and inducements 1-3 weeks too early. And I have to say, that isn’t something you see written down in Williams Obstetrics.

    Well, you wouldn’t expect to, would you?

  26. Andrew Leigh says:

    tigtog/LH, I posted the following on tigtog’s blog.

    Tigtog, we’re drifting a long way away from the original question. Let’s be clear: LH is arguing that c-sections and interventions are systematically performed 1-3 weeks too early, and therefore that a financial incentive to move those procedures back by 1-3 weeks will improve infant health. She cited some studies, all of which I regard as tainted by selection bias. So far as I can see, the only bit of randomised evidence on this point is the term breech study. But if you think it’s irrelevant to this discussion, then that’s fine – we can just go back to my previous point: which is that there is no medical consensus that c-sections and inducements are being done 1-3 weeks too early. All the studies that LH cites do not seem to have affected the medical consensus, at least as expressed in statements by the major professional bodies and the major textbooks.

    A more general point: I’m happy to engage in serious discussions, but the snarky tone that both of you have adopted doesn’t add anything to the substantive issues. Commenting pseudonymously isn’t a licence for rudeness.

  27. Joshua Gans says:

    I posted this on tigtog’s blog:

    You know I have been sitting here watching this debate and somehow think that it is all off point and that it is obscuring much more important points.

    First, we looked at the data (including birth weight) and saw that the government incentives caused birth delay, those delayed were planned birth timing and that the babies that were delayed were on average larger. We can be forgiven (a) for thinking that poor implementation of an economic policy was impacting on a medical choice was likely to be bad and (b) that if there was evidence that it was leading to larger babies that that might be bad too.

    Second, lauredhel’s point was not to dispute this but to dispute that this was ‘bad.’ Instead, the argument is that all other planned birth timings other than the 1st July 2004 and 2006 are bad in that they are occurring too early. I must say I can believe that because when the baby bonus was introduced some births appeared to be delayed by 2 weeks or more. You can’t do that I suspect unless babies were being planned 2 weeks or so earlier than they should be in general. That is what a statistical analysis does. (Also, in my own experience I saw that happen with one of our children). But excuse us for giving obstetricians the benefit of the doubt and thinking the baby bonus bump was the anomaly.

    So in lauredhel is correct, our research is only lending to arguments that planned deliveries are occurring too often and too early. Why disparage it? Moreover, why not add to that the 1st April and 29th February, obstetrics conference and indeed the whole weekend effect? What is going on there? These do not indicate a medical system working purely in the interests of health outcomes.

    Finally, let me ask some questions. If our research is so bad and our economic recommendation so foolish, why is the Royal College coming out and saying parents shouldn’t delay births around 1st July? So they say there is no medical problem but people shouldn’t do it? It doesn’t stack up. Why also has no maternity hospital administrator ever wanted to talk to us about this? Our concern was more about crowding in the first week of July than about slightly larger babies. Yet, no one will discuss it. That should be the concern here.

    One parting note to you tigtog: the undercurrent of all this is that two male economists can’t know what they are talking about when it comes to this stuff. Complete rot. I am an economist who has happened to have delivered two babies. I have seen action and know all about birth positions, delivery options and what they might mean. I also know that someone in the last couple of weeks of pregnancy is suffering beyond what those who have not gone through it should know. The idea that they might want to use assistance, especially safe assistance, to hurry things on a little is not hard to fathom. We need to put aside the notion that it is all about the baby and consider the other patient as well.

  28. tigtog says:

    A more general point: I’m happy to engage in serious discussions, but the snarky tone that both of you have adopted doesn’t add anything to the substantive issues. Commenting pseudonymously isn’t a licence for rudeness.

    When cite after cite after cite after cite is cavalierly dismissed, frustration arises. Snarkiness is a fairly common response to handwaving.

    I have been grateful for Joshua’s substantive engagement with our arguments against the interpretation of your data over at Hoyden.

    I want to reiterate the point here that I made there to Joshua’s comment that “the undercurrent of all this is that two male economists can’t know what they are talking about when it comes to this stuff”: none of this has anything to do with you two being male, although the fact that you are economists rather than biologists may well be relevant.

    Lauredhel and I are both trained in the health sciences. We see objections to your paper’s interpretations on both biological and hospital procedure grounds. That’s it.

  29. tigtog says:

    P.S. Just wanted to address this from Joshua

    I also know that someone in the last couple of weeks of pregnancy is suffering beyond what those who have not gone through it should know.

    I’ve been pregnant twice, and the only thing I “suffered” from in the last few weeks was impatience. Otherwise there were minor physical discomforts. So whose anecdote wins?

    Women who are enduring severe gestational distress should certainly be able to take measures to relieve their suffering, but not all (or even most?) women are “suffering” in both my personal and clinical experience.

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