Friday, August 2, 2013

Labor is not Euvoluntary: Labor Edition

I don't know what your experience is, but I can't recall Cesarean section births being all that common when I was a youngster. I still recall my surprise upon hearing that there was such a thing as a convenience C-section, usually scheduled well in advance. At first, I dismissed this as a fringe trend, disconnected from the actual experience of women, confined mostly to elite upper-middle class mothers.

I was wrong. From the CDC:


There are a lot of series on that graph, but the interesting one is the dashed line, for all births. In 1996, 19.7% of births were by C-Section, compared with 31.3% in 2011. It's a pity the time series doesn't go back farther, as I'd like to see what the rates were when we here at EE were born (the 50s and the 70s for Mike and me, and I think JR was born in the 80s), but the opportunity costs of fetching the data are too damn high. At any rate, this sort of thing doesn't happen just by accident: whoops, I tripped, fell on your scalpel and a baby popped out. No, there must be a tale of incentives, institutions, and relative prices in there.

And it wasn't until a chat with Mrs Spivonomist yesterday that I found the missing puzzle piece. Short-term disability.

At least here in the Commonwealth, short-term disability covers 6 weeks for vaginal birth and 8 weeks for C-section. Moreover, [employer redacted] grants extra paid time off for C-section recovery and no such benefit whatsoever for vaginal birth. I don't know if that's industry standard or not, but if it is, there's your story right there. Even more over, according to what I've been able to glean, this [employer redacted] policy is relatively new, a response to legitimate concerns that women who had medically necessary C-sections were being unfairly penalized by employment requirements. And that's true; recovery from invasive surgery takes time.

Knowing all that, it's kind of surprising that the slope on the graph above isn't steeper. Though, it is possible that the stale labor market has changed the relative prices. No sense shipping your good apples if nobody's buying. At any rate, it's kind of a relief to have a bit more insight into this odd outcome. I think it's at least a little bit easier to reject alternative hypotheses like all of a sudden placentas all across America have shifted out of place.

The last empirical question has to do with long-term outcomes. Will there be any interesting repercussions 20 years down the road? My priors say no, as I chiefly suspect that the big social ills come not from delivery method but from bad policy. Still, some economist two decades from now could do worse than to include a term for C-section birth rates in her regressions.

What are your moral intuitions about childbirth? How do you feel about midwifery? About scheduled C-sections? Should politicians and bureaucrats attempt to tinker with incentives that influence mothers' decisions? Why or why not? What's the appropriate moral calculus? Fairness? Justice? Care? What's the correct policy scale? National? State? Local? Personal? Please explain.

And if you do elect to have this conversation in class or with friends or family, please feel free to share your experiences in the comments or by e-mail. I'd love to follow up on the topic. I have one daughter and she was born at home, despite systematic pressures to deliver in a hospital under the supervision of a physician.


  1. Lawsuits. John Edwards.

  2. Anecdotally, through conversations with my sister-in-law (and, according to her, numerous friends of hers who have had children), one explanation for the rise in "convenience C-sections" is not only convenience for the mother but also for the doctors. By scheduling C-sections, they reduce the chance that they'll be working on a weekend or late in the evening. One reason she believes this is a big driver is that she and her friends have not only gotten advice to schedule C-sections but also to induce a little early (which can lead to emergent C-sections if the labor does not "take").


Do you have suggestions on where we could find more examples of this phenomenon?