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Scheduling births for non-medical reasons has become an increasingly common practice in the United States and around the world. We exploit a natural experiment created by child tax benefits, which rewards births that occur just before the new year, to better understand the full costs of elective c-sections and inductions. Using data on all births in the U.S. from 1990 to 2000, we first confirm that expectant parents respond to the financial incentives by electing to give birth in December rather than January. We find that most of the manipulation comes from changes in the timing of c-sections. Small birth timing changes, even at full-term, lead to lower birthweight, a lower Apgar score, and an increase in the likelihood of being low birthweight., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Hospitals and health care systems are already seeing the effect of health care reform with declining dollars. Hospital services, which had narrow financial margins in the past, will have further challenges. This article will review definitions, challenges, and potential financial solutions for labor and delivery units. Improving quality, efficiency, and cost requires substantial physician cooperation in the changing paradigm from physician-centric care to the transparent safety of teams. The financial contribution margin should increase the net revenue, but significant volumes are also needed. The challenge of this model for obstetrics is the slowing birth rate with the ultimate limitation for growth. Therefore, cost containment is imperative for sustainability. Standardization of hospital policies and procedures can improve quality and cost-savings with new incentive models. Examples include decreasing expensive pharmaceuticals, minimizing elective inductions of labor, and encouraging breast-feeding. As providers of health care to women, we all must engage in the triple aim of (1) improving the experience of care, (2) improving the health of populations, and (3) reducing per capita costs of health care. Although accountable care organizations presently are focused on Medicare populations for cost containment, all health care providers and institutions must be vigilant on both quality cost-effective care for sustainability, especially in obstetrics., (Copyright © 2013 Mosby, Inc. All rights reserved.)