After Midnight

My wife is American,  and we’ve often commented that we’re glad that she could give birth in Australia (where 1-week hospital stays are quite common) rather than the US (where the norm is more like 2-3 days). But a new NBER working paper suggests that perhaps our concerns are misplaced. I can’t fault the empirical strategy, though in an ideal world I would have liked more fine-grained outcome measures than readmission and infant mortality.

After Midnight: A Regression Discontinuity Design in Length of Postpartum Hospital Stays
Douglas Almond and Joseph Doyle
Patients who receive more hospital treatment tend to have worse underlying health, confounding estimates of the returns to such care. This paper compares the costs and benefits of extending the length of hospital stay following delivery using a discontinuity in stay length for infants born close to midnight. Third-party reimbursement rules in California entitle newborns to a minimum number of hospital “days,” counted as the number of midnights in care. A newborn delivered at 12:05 a.m. will have an extra night of reimbursable care compared to an infant born minutes earlier. We use a dataset of all California births from 1991-2002, including nearly 100,000 births within 20 minutes of midnight, and find that children born just prior to midnight have significantly shorter lengths of stay than those born just after midnight, despite similar observable characteristics. Furthermore, a law change in 1997 entitled newborns to a minimum of 2 days in care. The midnight discontinuity can therefore be used to consider two distinct treatments: increasing stay length from one to two nights (prior to the law change) and from two to three nights (following the law change). On both margins, we find no effect of stay length on readmissions or mortality for either the infant or the mother, and the estimates are precise. The results suggest that for uncomplicated births, longer hospitals stays incur substantial costs without apparent health benefits. 

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6 Responses to After Midnight

  1. Mark Jones says:

    We’ve spent the past 15 year living in the Dutch system. One of our children was born at home the other with complications in a hospital. In NL today 55% of all birth are natural 20% czar and 25% asisted births. 50 yrs ago the czar was about 3% and assisted births 5%. A. van Lonkhuyzen suggests that with hospitalization there is a dramatic increase in the number of interventions. I mean if Im a hammer – Im looking for a nail!
    Perhaps the innovation here is a shift of mindset & behaviouor. To build self confidence and deepen the intuitive capability in future mums so that they can do it themselves @ home and only head to the hospital when there really is a problem!

  2. Patrick says:

    There is almost never any need for the hospitalisation. We prefer to actually give birth in a hospital, but with the midwives. It is just reassuring to have a full emergency and resuscitation room a lift away.

    That said, now that we are coming to our third my wife is starting to think that a few extra days peace and quiet might be valuable in and of itself 🙂

  3. Seems to me that if cutting health costs is the agenda then we’d be better off tackling Australia’s very high proportion of caesareans which rose from 19.4% of all births in 1994 to 29.1% by 2004 (and has probably risen even further since then). While many caesars are unavoidable and save lives, experts suggest that there is an increasing trend toward elective caesars that are not necessary. The data would suggest that something unusual is going on in Australia.

  4. Anthony says:

    Yeah, like Patrick said, and in my partner’s case it turned out a good thing because of massive blood loss in the third stage. But Andrew, are one-week stays common in Australian hospitals? All my friends got booted out of Melbourne hospitals after three days – including my partner, who was simply given a blood transfusion the night before so she could walk out of the hospital unassisted

  5. DLB says:

    Andrew, I wonder why you and your wife are attracted to the week-long post-partum stay c.f. with the US practice? Is it a medically based view (not meaning to get personal), or is to give ‘mum’ some time to recover. Nothing wrong with the latter, I hasten to add! In my experience of my wife having our 2 children, both born by C-section at a DGH in West London, I am all for hospital deliveries. Our first (her 2nd by C-section) was an uncomplicated birth and was normal in the initial post-partum period but had an unknown congenital heart defect which became evident c.18hrs after birth and had to be medically retrieved to a major London kids’ hospital for repair and 2 weeks in neonatal ICU. Then our 2nd, also a C-section, was delivered without problem but mum and daughter were discharged just short of 24hrs as they were the last patients on the ward and the hospital wanted to close the ward as they did not have sufficient staff! We had a nervous few days at home after this. It is worth noting that there are profound changes in the infant’s circulation between heart & lungs in the first few days to one week after birth. Mind you, in the UK system, a specialist nurse visits at home twice a week for the first 6 weeks or so (I think) to keep tabs on progress and development, which is very good. In addition, my sister had her first child in California and ended up being readmitted with septicaemia from a partially undelivered placenta. The problem here, when she represented post-partum on a number of occasions at her hospital with fever and disorientation, was that she did not see a medic as she could not get past the “physician’s assistant” (a nurse) who would send her home telling her that she would be fine. Give me our system any day, even if we have to pay for it! Surely our society can absorb this cost for the newborns – it is not ALL about economic rationalism, is it??

  6. Verdurous says:


    re: “But Andrew, are one-week stays common in Australian hospitals?”

    One week stays are more common in private hospitals or following caesareans or complicated births. In public hospitals its 2-3 days.

    I recall one lady (10th child) in Coff’s Harbour Base Hospital (where I worked) who stayed for about 90 minutes after the birth. No messing about there.

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