The (temporary) Covid-19 baby bust in Mexico.

In this paper, we investigate whether fertility and newborn health changed during the Covid-19 pandemic in Mexico. We use national administrative data and an event-study design to examine the impact of the Covid-19 pandemic on fertility and newborn health characteristics. Our findings suggest that Mexico's fertility declined temporarily as measured by conceptions that likely occurred during the stay-at-home order. Initially, the general fertility rate fell by 11-12 per cent but quickly rebounded and returned close to its original levels by the end of 2021. Newborn health also deteriorated during the pandemic. Instances of low birthweight and prematurity substantially increased, with both remaining elevated over the entire pandemic period.

An alternative model of maternity care for low-risk birth: Maternal and neonatal outcomes utilizing the midwifery-based birth center model.

OBJECTIVE: To assess key birth outcomes in an alternative maternity care model, midwifery-based birth center care. DATA SOURCES: The American Association of Birth Centers Perinatal Data Registry and birth certificate files, using national data collected from 2009 to 2019. STUDY DESIGN: This observational cohort study compared key clinical birth outcomes of women at low risk for perinatal complications, comparing those who received care in the midwifery-based birth center model versus hospital-based usual care. Linear regression analysis was used to assess key clinical outcomes in the midwifery-based group as compared with hospital-based usual care. The hospital-based group was selected using nearest neighbor matching, and the primary linear regressions were weighted using propensity score weights (PSWs). The key clinical outcomes considered were cesarean delivery, low birth weight, neonatal intensive care unit admission, breastfeeding, and neonatal death. We performed sensitivity analyses using inverse probability weights and entropy balancing weights. We also assessed the remaining role of omitted variable bias using a bounding methodology. DATA COLLECTION: Women aged 16-45 with low-risk pregnancies, defined as a singleton fetus and no record of hypertension or cesarean section, were included. The sample was selected for records that overlapped in each year and state. Counties were included if there were at least 50 midwifery-based birth center births and 300 total births. After matching, the sample size of the birth center cohort was 85,842 and the hospital-based cohort was 261,439. PRINCIPAL FINDINGS: Women receiving midwifery-based birth center care experienced lower rates of cesarean section (-12.2 percentage points, p < 0.001), low birth weight (-3.2 percentage points, p < 0.001), NICU admission (-5.5 percentage points, p < 0.001), neonatal death (-0.1 percentage points, p < 0.001), and higher rates of breastfeeding (9.3 percentage points, p < 0.001). CONCLUSIONS: This analysis supports midwifery-based birth center care as a high-quality model that delivers optimal outcomes for low-risk maternal/newborn dyads.

Race, ethnicity, and indications for primary cesarean birth: Associations within a national birth center registry.

BACKGROUND: Racial and ethnic disparities in cesarean rates in the United States are well documented. This study investigated whether cesarean inequities persist in midwife-led birth center care, including for individuals with the lowest medical risk. METHODS: National registry records of 174,230 childbearing people enrolled in care in 115 midwifery-led birth center practices between 2007 and 2022 were analyzed for primary cesarean rates and indications by race and ethnicity. The lowest medical risk subsample (n = 70,521) was analyzed for independent drivers of cesarean birth. RESULTS: Primary cesarean rates among nulliparas (15.5%) and multiparas (5.7%) were low for all enrollees. Among nulliparas in the lowest-risk subsample, non-Latinx Black (aOR = 1.37; 95% CI, 1.15-1.63), Latinx (aOR = 1.51; 95% CI, 1.32-1.73), and Asian participants (aOR = 1.48; 95% CI, 1.19-1.85) remained at higher risk for primary cesarean than White participants. Among multiparas, only Black participants experienced a higher primary cesarean risk (aOR = 1.49; 95% CI, 1.02-2.18). Intrapartum transfers from birth centers were equivalent or lower for Black (14.0%, p = 0.345) and Latinx (12.7%, p < 0.001) enrollees. Black participants experienced a higher proportion of primary cesareans attributed to non-reassuring fetal status, regardless of risk factors. Place of admission was a stronger predictor of primary cesarean than race or ethnicity. CONCLUSIONS: Place of first admission in labor was the strongest predictor of cesarean. Racism as a chronic stressor and a determinant of clinical decision-making reduces choice in birth settings and may increase cesarean rates. Research on components of birth settings that drive inequitable outcomes is warranted.

Health outcomes and provider choice under full practice authority for certified nurse-midwives.

Full practice authority grants non-physician providers the ability to manage patient care without physician oversight or direct collaboration. In this study, we consider whether full practice authority for certified nurse-midwives (CNMs/CMs) leads to changes in health outcomes or CNM/CM use. Using U.S. birth certificate and death certificate records over 2008-2019, we show that CNM/CM full practice authority led to little change in obstetric outcomes, maternal mortality, or neonatal mortality. Instead, full practice authority increases (reported) CNM/CM-attended deliveries by one percentage point while decreasing (reported) physician-attended births. We then explore the mechanisms behind the increase in CNM/CM-attended deliveries, demonstrating that the rise in CNM/CM-attended deliveries represents higher use of existing CNM/CMs and is not fully explainable by improved reporting of CNM/CM deliveries or changes in CNM/CM labor supply.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes.

OBJECTIVES: Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. METHODS: This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. RESULTS: The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. CONCLUSIONS FOR PRACTICE: Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Marriage and divorce during a pandemic: the impact of the COVID-19 pandemic on marital formation and dissolution in Mexico.

In this study, we consider the initial effects of the COVID-19 pandemic on family formation and dissolution. We use national microdata covering all marriages and divorces in Mexico, an event-study design and a difference-in-difference specification. Our findings indicate that over March through December of 2020, marriage rates declined by 54% and divorce rates by 43%. By the end of 2020, divorce rates recover back to baseline levels, but marriage rates remain 30% below the 2017-2019 baseline level. Overall, our findings suggest that marital dissolutions quickly recovered (6 months into the pandemic), but at the end of 2020, family formation remained at persistently lower levels.

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care.

INTRODUCTION: The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families. METHODS: Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors). RESULTS: After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts. DISCUSSION: The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

City Health Departments, Public Health Expenditures, and Urban Mortality over 1910-1940.

Over the early twentieth century, urban centers adopted full-time public health departments. We show that opening full-time administration had little observable impact on mortality. We then attempt to determine why health departments were ineffective. Our results suggest that achievements in public health occurred regardless of health department status. Further, we find that cities with and without a full-time health department allocated similar per capita expenditures towards health administration. This health department funding also better predicts infant mortality declines. Our conclusions indicate that specific campaigns, public health systems, and funding may have been more meaningful for local health over this era.

Salary and Workload of Midwives Across Birth Center Practice Types and State Regulatory Structures.

INTRODUCTION: Expansion of the midwifery-led birth center model of care is one pathway to improving maternal and newborn health. There are a variety of practice types among birth centers and a range of state regulatory structures of midwifery practice across the United States. This study investigated how those variations relate to pay and workload for midwives at birth centers. METHODS: Data from the American Association of Birth Centers Practice Survey and the Bureau of Labor Statistics' report on occupational employment and wage statistics were analyzed to explore how midwife salaries and workload at birth centers compare within and beyond the birth center model. RESULTS: Survey results from 161 birth centers across the United States demonstrate wide variation in nurse-midwife salaries and are inconsistent with nurse-midwife salaries across all settings as reported by the Bureau of Labor Statistics. The reported number of hours worked by midwives within the birth center model is high. Salaries of midwives who work in birth center-only practices were consistently lower than salaries of midwives who worked in blended birth center and hospital practices, independent of the midwife's level of experience, geographic region of the country, and state regulatory structure. DISCUSSION: Further research is needed to understand how to bring salaries and workload for midwives at birth centers into alignment with national averages.

The impact of the COVID-19 recession on Mexican households: evidence from employment and time use for men, women, and children.

This study examines changes in labor supply, income, and time allocation during the COVID-19 pandemic in Mexico. Using an event-study design, we show that the COVID-19 recession had severe negative consequences for Mexican households. In the first month of the pandemic, employment declined by 17 percentage points. Men recovered their employment faster than women, where men's employment approaches original levels by 2021Q2. Women, on the other hand, experienced persistent employment losses. Within-household, men also increased their time spent on household chores while neither gender (persistently) increased their time caring for others. Instead, children reduced their time spent on schoolwork by 25%.

The U-shaped crime recovery during COVID-19: evidence from national crime rates in Mexico.

The existing empirical evidence suggests a reduction in aggregate crime as a consequence of the COVID-19 lockdown. However, what happens when lockdown measures are relaxed? This paper considers how the COVID-19 pandemic affects crime rates throughout Mexico when the stay-at-home orders end. We use national crime data from Mexico's National Public Security System, which reports municipality-level rates on assault & battery, theft & property crime, fraud, drug crimes & extortion, and homicides. Our results show that the majority of crimes follow a U-shaped trend-when the lockdown ends-crimes rise back to pre-pandemic levels.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy.

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

COVID-19 blues: Lockdowns and mental health-related google searches in Latin America.

RATIONALE: Stress process theory considers that actual and perceived isolation, caused by mobility restrictions from attempted containment of the COVID-19 pandemic, deteriorates mental health. OBJECTIVE: We examine the relationship between the COVID-19 lockdowns and mental health-related Google searches in 11 Latin American countries. We include the following countries: Argentina, Bolivia, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Peru, and Uruguay. We also explore how changes in search patterns relate to income support policies and to COVID-19 death rates. METHOD: Using Google Trends data and an event-study design, as well as a difference-in-differences analysis, we investigate the association between country specific stay-at-home orders and internet searches including the following words: insomnia, stress, anxiety, sadness, depression, and suicide. RESULTS: We find three main patterns. First, searches for insomnia peak but then decline. Second, searches for stress, anxiety, and sadness increase and remain high throughout the lockdown. Third, there is no substantial change in depression-related or suicide-related searches after the lockdown. In terms of potential mechanisms, our results suggest that searches declined for suicide and insomnia following the passage of each country's income support, while in countries with higher COVID-19-related death rates, searches for insomnia, stress, and anxiety increased by more. CONCLUSIONS: Our results suggest that, in Latin America, Google searches for words associated with mild mental health disorders increased during the COVID-19 stay-at-home orders. Nonetheless, these conclusions should not be construed as a general population mental health deterioration, as we cannot verify that search indicators are accurately related to the users' current feelings and behaviors, and as internet users may not be representative of the population in this region.

COVID-19 and women's health: Examining changes in mental health and fertility.

Researchers have speculated that the economic and social consequences of COVID19 will harm women's health. This paper tests this claim in the immediate aftermath of Mexico City's COVID-19 stay-at-home order using call-center data. We use an event-study design to track calls for fertility decisions and mental health. Our findings indicate that mental health worsened during the pandemic. Anxiety calls increased substantially, with the effect being most pronounced for those over 45. Calls related to abortion fell in number, while pregnancy calls remained stable. The abortion effect is most pronounced for women between 15 and 30 and those with a high school degree.

The great crime recovery: Crimes against women during, and after, the COVID-19 lockdown in Mexico.

This paper considers whether the COVID-19 stay-at-home order affected crimes targeting women. To answer this question, we use national municipal-level crime data from Mexico's National Public Security System. The NPSS reports sexual crimes, lapses in alimony, domestic violence, and femicides. Using the NPSS, we track monthly changes in crimes targeting women using an event-study design. Our results show that lapses in alimony, sexual crimes, and domestic violence follow a U-shaped trend. Each crime declined during the stay-at-home order, and then rose back to pre-COVID levels by October. Then, we analyze potential mechanisms for the reduction in crimes against women. We find that infection risk, victim-criminal match, and banning the sale of alcohol are related to higher declines in crime.

Druglords don't stay at home: COVID-19 pandemic and crime patterns in Mexico City.

OBJECTIVE: To investigate the effect of the COVID-19 pandemic on conventional crime and organized crime in Mexico City, Mexico. METHODS: Mexico City's Attorney General's Office reported crime data, covering domestic violence, burglary, robbery, vehicle theft, assault-battery, homicides, kidnapping, and extortion. We use an event study for the intertemporal variation across the 16 districts (municipalities) in Mexico City for 2019 and 2020. RESULTS: We find a sharp decrease on crimes related to domestic violence, burglary, and vehicle theft; a decrease during some weeks on crimes related to assault-battery and extortion, and no effects on crimes related to robbery, kidnapping, and homicides. CONCLUSIONS: While our results show a decline in conventional crime during the COVID- 19 pandemic, organized crime remains steady. These findings have policy implications for catastrophic events around the world, as well as possible national security issues in Mexico.

Rural resilience: The role of birth centers in the United States.

PURPOSE: To explore the role of the birth center model of care in rural health and maternity care delivery in the United States. METHODS: All childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data RegistryTM user sites between 2012 and 2020 are included in this descriptive analysis. FINDINGS: Between 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data RegistryTM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities. CONCLUSIONS: Rural populations cared for within the birth center model of care experienced high-quality outcomes. HEALTH POLICY IMPLICATIONS: A major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.