Born on a Busy Day: Midwives Buffer Effects of Crowded Wards on Babies and Mothers

Hans Sievertsen and Michelle Kilfoyle
22 November 2021

The recent demands of Covid-19 have seen hospital patient numbers soar. A better understanding of how crowding on wards affects treatments and patient outcomes is essential in helping clinicians best allocate their care – both during the pandemic and beyond, and for all sectors of hospital care. Taking maternity wards as an example, a recent Danish study of nearly 800,000 births finds that midwives adjust their care strategies for mothers to ease workload pressure during busy periods. Surprisingly, the shifts in treatment – fewer inductions and later admission to hospital – bring no obvious signs of harm to mother and child.

Evidence on the effects of crowding is scarce, especially for maternity wards. Much like A&E, maternity wards face the challenge of unpredictable admission rates that are hard to plan for. The new study, by Hans Sievertsen from the University of Bristol’s Centre for Evidence-based Public Services (CEPS) and School of Economics, starts to fill this knowledge gap for maternity wards.

Working with a team of researchers from Aarhus University and the University of Copenhagen, Sievertsen analysed birth registry and medical data for 796,416 babies born during 2000–2014 and their mothers across Denmark. They focused on uncomplicated births, thus excluding those born by planned caesarean.

The research team assessed how treatment and patient outcomes varied according to the number of patients admitted to a maternity ward for each day. Admissions can substantially and rapidly fluctuate on Danish maternity wards, and surges of 200% above the average are not uncommon.

As an example of how patient numbers vary, daily admissions on Denmark’s busiest maternity ward, Hvidovre, range between six and 25.

Their results showed that midwives appear to ease pressure on busy days by choosing not to speed-up delivery by avoiding or postponing inductions. For each three additional admissions over the average, there was a 0.7 percentage point reduction in the number of inductions. This corresponds to a 4% reduction on the average induction rate of 18.6% across all the births studied.

In addition, midwives appear to admit mothers into hospital at slightly later stages of labour during busy periods, thus reducing the overall length of time that mothers spend in hospital.

Of surprise to the research team, crowding presented no obvious health risks to either mother or baby, based on various measures of wellbeing and indicators of care.

For instance, there was no increase in stillbirths or death rates among babies within the first week and year of life. It should be noted that these are rare occurrences in any case, and the study only looked at non-risky births.

For babies, there was no effect on their APGAR score – the quick health test performed immediately after birth to assess five key factors, including breathing and heart rate.

For mothers, there was no increase in the probability of having an emergency caesarean, the rate or severity of lacerations (vaginal tearing), or delay in epidural pain relief. Skin-to-skin contact with baby within two hours of birth, a central quality indicator for Danish hospitals, continued to take place in timely fashion.

Further, children born on crowded maternity wards and their mothers were no more likely than other families to access healthcare – whether GPs or hospitals – in the two years post-birth.

In fact, the study even found that there were fewer serious post-birth complications for mothers who gave birth on busy days: a 1.5% reduction, approximately, for each three extra births over the average. The researchers speculate that this may be because the lower number of inductions on crowded days reduced the need for follow-up treatments associated with this procedure.

The study, therefore, shows that Danish maternity wards’ strategies to ease workload pressure enable midwives to cope with day-to-day spikes and dips in patient numbers, and without detectable health risks for the majority of uncomplicated births. The authors do stress, however, that their results cannot be used as evidence in support of cuts to hospital funding, as they did not examine what the optimal level of maternity care should be.


Hans Sievertsen – Senior Lecturer in Economics – University of Bristol
Michelle Kilfoyle – CEPS Science Writer and Editor

Gender Stereotypes See Female Criminals Fare Better in Court

Michelle Kilfoyle and Arnaud Philippe
17 November 2021

The criminal justice system represents a rare sector of society where women fare better than men. Female criminals are less likely to be arrested, sent to court and sentenced than male offenders, even for equivalent crimes. Where women are sentenced, their punishments are usually less severe.

New research concludes that the differences in sentencing for men and women are due to gender stereotyping of defendants in court. Protective, paternalistic attitudes of male judges towards female defendants seem to be a key reason for the more lenient punishments handed to women.

Official statistics from France, the UK and the USA all show the preferential treatment of women throughout the criminal justice system. The new study, by Arnaud Philippe of the University of Bristol’s School of Economics and Centre for Evidence-based Public Services (CEPS), draws on criminal court data to both confirm and quantify genuine differences between sentences for men and women in France, and to find reasons for this gender gap.

Philippe analysed data for 1.37 million convictions in France between 2000 and 2003 for a criminal category called delits in French. This covers most forms of crime: property crimes, violent crimes, economic crimes, insults, drug-related crimes and road-related offenses.

The average prison sentence for men was 47 days, and 19 days for women. Having accounted for the influence of non-gender factors on sentencing, such as the form of crime, the defendant’s history of criminal activity and their socioeconomic characteristics, the study found that gender was responsible for a 15-day difference in sentence lengths for men and women. Women were also slightly more likely to receive suspended prison sentences.

Digging deeper into the data, Philippe homed in on court cases featuring just two people on trial, one man and one woman, convicted of the same crime. This enabled an even clearer picture of just how gender influences sentencing when other factors are equal, in particular, the judges and prosecutor working on the trial, and the trial’s time and place.

The sentencing gender gap was even more striking for these 2382 mixed-gender pairs. Women’s prison sentences were, on average, 25.6 days shorter than men’s and their probation sentences 2.4 days shorter. Men received longer prison sentences even if their female partner had a longer history of committing crimes – a factor normally associated with harsher sentencing.

Notably, the differences between sentences for men and women were smaller in trials with more female judges in court. Three judges work on each court case for delits, and an increase in the share of female judges of around 20% was associated with 1.5 days longer prison sentences for women, and 1.7 days longer probation. The gender of the prosecutor had no influence on sentencing rates or harshness.

The study’s findings suggest that gender stereotyping by judges was the main driver of the sentencing gender gap. Drawing on wider evidence from the US, Philippe points to the influence of paternalism among male judges, who may view women as fragile and perhaps less able to cope with prison.

These results reflect a common pattern in society whereby individuals tend to discriminate less against people of a similar demographic to themselves. In this case, female judges were less likely to positively discriminate towards female criminals.

The results do not support other possible explanations for the disparities, such as the need to adhere to the criminal code. This might, conceivably, see mothers treated less harshly for their

children’s sake as part of judges’ obligations to protect society, for instance, but this was not shown by the data.

As well as providing clear evidence of discrimination between men and women in court, the study also demonstrates the broader value of diversity among decision makers in reducing discrimination


Michelle Kilfoyle – CEPS Science Writer
Arnaud Philippe – Senior Lecturer, School of Economics

Overconfidence in Health Linked with Unhealthy Lifestyles According to Economic Report

Michelle Kilfoyle and Patrick Arni
10th November 2021

Rising healthcare costs have intensified the focus on nudging the public towards healthier lifestyles. But what if you mistakenly believe your health to be better than it really is? New research shows that many people are just not as healthy as they think they are, and that this overconfidence hikes up the risk of adopting unhealthy behaviours, such as regularly eating junk food or taking no exercise. Public health campaigns that give individuals a better understanding of their true health status could, therefore, help foster healthier lifestyles, the findings suggest.

For economists, health behaviours can be understood in terms of their perceived costs and benefits to the individual. Even if people know that drinking alcohol or eating junk food carries health risks, many still enjoy doing so.

The weight assigned to either cost or benefit is partly shaped by how healthy we consider ourselves to be in the first place and what we believe our bodies can tolerate. We may reason that “I’m healthy enough to ‘afford’ to drink a little alcohol every day” or “I can’t ‘afford’ the health risks of a couch-potato lifestyle”. The study, co-authored by Patrick Arni of the University of Bristol’s Centre for Evidence-based Public Services (CEPS) in the School of Economics, introduces the concept of ‘biased health perceptions’ to describe how people overestimate their health and how these misperceptions are strongly linked to unhealthy behaviours.

As part of an international research team, with colleagues from the Universities of Bologna and Bonn, and Cornell University, Arni analysed data from three large-scale health surveys from Germany which together covered nearly 7,000 adults..

These surveys included objective measures of health, namely blood pressure and cholesterol readings taken by health professionals, which can be used as proxies for physical health. Further, the surveys questioned the respondents on their health to develop a reliable measure of their overall health status, as well as their health behaviours and perceptions of their health.

The research team used these data to calculate the gap, or biased health perception, between actual and assumed levels of health.

They found that 30% of the respondents were unaware that they had high cholesterol, while 9% did not realise that their blood pressure was high.

A clear majority of respondents thought that they were as healthy or healthier than most other people of their age when presented with the question: Imagine randomly selecting 100 people of your age. How many of those 100 people would be in better health than you?.

Thirty percent of respondents placed themselves at least 30 places higher in this ranking system than their overall health status would indicate. If the answers had accurately represented people’s true health, then they would have been spread more evenly across the distribution..

The analysis revealed clear correlations in the data between biased perceptions and behaviours. Respondents who were overconfident in their health were more likely to have unhealthy lifestyles, in that they were more prone to eating junk food, drinking alcohol daily, taking no exercise and not getting enough sleep.

For instance, 54% of the respondents who were unaware that their cholesterol levels were high did no exercise at all, compared with 43% of those who were aware of high cholesterol levels. These biased respondents were also 50% more likely to drink alcohol daily, and to have higher BMIs.

Further, 50% of people who overestimated their health in relation to other people did not exercise at all, compared with the 30% who accurately or underestimated their health.

The findings point to several public health interventions. Those with biased health perceptions could be targeted for public health campaigns aimed at reducing risky health behaviours. Regular health check-ups and screenings, in addition to nudging people to seek regular feedback about their health, could also be effective.

Interestingly, biased health perceptions were not linked to smoking habits. This is probably because addiction to smoking overrides any calculations of costs to health. Hence, public health campaigns that focus on the health costs of smoking are likely less effective at curbing tobacco consumption than tougher regulatory measures, such as smoking bans.


Michelle Kilfoyle – CEPS Science Writer
Dr. Patrick Arni – University of Bristol School of Economics

Study Reveals How High-Stakes Tests Spur Girls to Study Harder

Michelle Kilfoyle and Hans Sievertsen
3rd November 2021

A-level results day this summer once again put grading systems under the spotlight in the UK, reigniting public debate on the potential need for grading reform.

Recent research from the University of Bristol’s Centre for Evidence-based Public Services (CEPS) and School of Economics, conducted in collaboration with the Danish Center for Social Science Research (VIVE), provides key information on the value of such high-stakes grades for students, and the possible effects of changes to grading systems.

In 2007, Danish high schools took the unusual step of re-coding students’ exam results for the previous year as part of a national educational reform. Consequently, while some of these students were awarded a higher Grade Point Average (GPA), a score that is critical to university applications, others saw their GPA fall.

The study took this unique opportunity to explore how grades affect student motivation. It showed that first-year high-school students ramped up their efforts in response to downgraded GPAs and, following this, were more likely to go to university. This was especially true for girls.

Knowing what motivates students to put more effort into their studies not only helps address under-performance. It can also help tackle social inequalities by identifying effective incentives for students whose parents have fewer means or resources than more advantaged families to promote their children’s performance at school.

Other studies on this topic have shown that financial rewards, such as vouchers, encourage students to work harder. Surprisingly, although grades are a more obvious form of ‘reward’, their effects on student behaviour are little researched and often overlooked in policy discussions.

This new study, conducted by  Hans Sievertsen of CEPS and Ulrik Hvidman of VIVE, provides strong real-world evidence that grades do provide an incentive for study. While, intuitively, this may seem apparent, it is particularly hard to prove in practice.

Sievertsen and Hvidman analysed the grades of 26,759 high-school students whose first-year exams had been re-scored under the Danish Grading Reform of 2007.

Introduced by the Ministry of Education as part of efforts to align Denmark’s education system with those of other European countries, the new grading system for secondary and post-secondary schools worked on a 7-point scale, in contrast to the previous 10-point method.

Examiners, thus, had fewer grades to select from, meaning that work graded ‘9’ under the 10-point system, for instance, received ‘7’ under the new system. The new mark did not represent a re-evaluation of the student’s ability; it was purely a re-coding with both grades indicating the same level of performance.

Some students benefited from this complex re-coding scheme, and received a higher GPA, the score that shows a student’s average grade across all courses and which carries high stakes given its use in university admissions processes. However, others lost out and scored lower GPAs. For many students their GPA represents a passport to their post-school education and career of choice, and so potentially shapes their lifelong earnings.

The re-coding, therefore, raised big questions of how students would behave in response to the shock of being downgraded for the remainder of their schooling.

The analysis revealed that downgraded first-year students performed better in subsequent assessments. Those who were downgraded by one standard deviation (approximately one grade point) scored 8% of a standard deviation higher in second- and third-year assessments, which also carry greater weight towards final GPAs. This suggests that these students had upped their effort levels to meet a ‘target’ GPA.

High-achieving students (those with above average GPAs) and, perhaps surprisingly, girls made the greatest leaps in effort.  Girls nearly cancelled out the effect of downgrading through increased efforts – making up 95% of the lost score, on average – compared with just 37% for boys. This may be partly explained by girls’ higher levels of non-cognitive skills, such as being more forward-looking in life.

The study brings new insights into the gendered effects of grades as incentives, while also showing that the relatively ‘small’ solution of placing more emphasis on high-stakes grades could be very effective in raising student performance and ambitions. This is likely to be true for other countries that rely on post-secondary assessment for university enrollment, such as the US and countries across Europe.


Authors

Michelle Kilfoyle – CEPS Science Writer
Hans Sievertsen – Professor of Economics, University of Bristol