Clinical Capital and the Risk of Maternal Labor and Delivery Complications: Hospital Scheduling, Timing, and Cohort Turnover Effects.

The establishment of interventions to maximize maternal health requires the identification of modifiable risk factors. Toward the identification of modifiable hospital-based factors, we analyze over 2 million births from 2005 to 2010 in Texas, employing a series of quasi-experimental tests involving hourly, daily, and monthly circumstances where medical service quality (or clinical capital) is known to vary exogenously. Motivated by a clinician's choice model, we investigate whether maternal delivery complications (1) vary by work shift, (2) increase by the hours worked within shifts, (3) increase on weekends and holidays when hospitals are typically understaffed, and (4) are higher in July when a new cohort of residents enter teaching hospitals. We find consistent evidence of a sizable statistical relationship between deliveries during nonstandard schedules and negative patient outcomes. Delivery complications are higher during night shifts (OR = 1.21, 95% CI: 1.18-1.25), and on weekends (OR = 1.09, 95% CI: 1.04-1.14) and holidays (OR = 1.29, 95% CI: 1.04-1.60), when hospitals are understaffed and less experienced doctors are more likely to work. Within shifts, we show deterioration of occupational performance per additional hour worked (OR = 1.02, 95% CI: 1.01-1.02). We observe substantial additional risk at teaching hospitals in July (OR = 1.28, 95% CI: 1.14-1.43), reflecting a cohort-turnover effect. All results are robust to the exclusion of noninduced births and intuitively falsified with analyses of chromosomal disorders. Results from our multiple-test strategy indicate that hospitals can meaningfully attenuate harm to maternal health through strategic scheduling of staff.