¿Puede un mayor salario para las matronas conllevar mejor salud? La experiencia neerlandesa con los cuidados prenatales

Este Blog resume (en inglés) el trabajo “Effects of Midwives’ Remuneration on Birth Outcomes. Evidence from the Netherlands”, por Joaquim Vidiella-Martin, Tom van Ourti (Erasmus School of Economics y Tinbergen Institute) y Loes Bertens (Erasmus Medical Centre), y que obtuvo el Premio SESPAS a la mejor Comunicación de Salud Pública en las XXXIX Jornadas de Economía de la Salud celebradas en Albacete del 12 al 14 de junio de 2019.

Early childhood health, including in utero exposure, has an enormous influence on adult health and economics outcomes. This fact has motivated policy-makers to devote remarkable resources to understanding the nature of early health outcomes. This is particularly true in the Netherlands, a country that had amongst the highest perinatal mortality and morbidity rates in Europe in the early 2000s. The Netherlands not only compares unfavourably to other similar European countries on average, but also has large regional inequalities, even within the same city. Several nationwide policies aimed at improving perinatal health have been implemented, but little is known about their impact on perinatal outcomes.

In our paper, we exploit one of these policies –a change in the remuneration received by midwives working in deprived areas in 2009- and assess its effects on birth outcomes. We show that the reform led to a modest improvement in perinatal health of the new-borns whose mother was treated, compared to those whose mother was not. Our research contributes to three strands of literature: (i) the analysis of the role of financial incentives on healthcare professionals’ performance; (ii) the understanding of the determinants of perinatal health; and (iii) the assessment of inequalities in health outcomes.

We exploit the nature of the reform to identify its causal impact. Each neighbourhood is given a deprivation score (s) by an independent institute. Midwives working with mothers who live in neighbourhoods over a given level of deprivation (s>s*, where s* is the cut-off point) were entitled to an increased fee obtained per woman cared for, while the same midwives would only receive the standard fee for mothers living in non-deprived areas (where s<s*). Using a conventional regression discontinuity framework, we could evaluate the effects of the reform on birth outcomes. However, our study would then be confounded by a related policy which started in 2000, and which provides additional remuneration to GPs working in deprived areas and uses the same threshold s*. We overcome the presence of such confounding policy by using a difference-in-discontinuity approach. More precisely, we exploit a discontinuity along deprivation scores before and after the policy was introduced (2009), to isolate the causal effect of additional remuneration on birth outcomes. We make use of several sources of Dutch administrative data to obtain information on birth outcomes, socioeconomic characteristics of the parents, as well as of the neighbourhoods in which they live in.

Our results point at a modest increase in gestational age (around 1 day on average), a mild increase in average birth weight (around 30 grams), and a reduction in the share of babies categorised as ‘small for gestational age’ (around 25 per 1,000 births). These averages may mask heterogeneity in treatment effects, which will be further explored. Similarly, further analysis is required to understand the mechanisms explaining our findings. In other words, future work will try to pin down which factors changed after the reform and helped decrease perinatal morbidity among new-borns.

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