It's about time: Cesarean sections and neonatal health.

Cesarean sections have been associated in the literature with poorer newborn health, particularly with a higher incidence of respiratory morbidity. Most studies suffer, however, from potential omitted variable bias, as they are based on simple comparisons of mothers who give birth vaginally and those who give birth by cesarean section. We try to overcome this limitation and provide credible causal evidence by using variation in the probability of having a c-section that is arguably unrelated to maternal and fetal characteristics: variation by time of day. Previous literature documents that, while nature distributes births and associated problems uniformly, time-dependent variables related to physicians' demand for leisure are significant predictors of unplanned c-sections. Using a sample of public hospitals in Spain, we show that the rate of c-sections is higher during the early hours of the night compared to the rest of the day, while mothers giving birth at the different times are similar in observable characteristics. This exogenous variation provides us with a new instrument for type of birth: time of delivery. Our results suggest that non-medically indicated c-sections have a negative and significant impact on newborn health, as measured by Apgar scores, but that the effect is not severe enough to translate into more extreme outcomes.