This dissertation consists of three essays in health economics, paying special attention to neonatal care provision and newborn health outcomes in the United States. The first chapter evaluates physician productivity, focusing on the matching between physician skills and patient conditions. High U.S. spending on health care is commonly attributed to its intensity of specialized, high-tech medical care. A growing body of research focuses on physicians whose medical decisions shape treatment intensity, costs, and patient outcomes. Often overlooked in this research is the assignment of physician skills to patient conditions, which may strongly affect health outcomes and productivity. This matching may be especially important in the case of hospital admissions as high-frequency fluctuations in patient flow make it challenging to maintain effective matches between the best-suited physicians and their patients. This paper focuses on hospitals’ responses to demand shocks induced by unscheduled high-risk admissions. I show that these demand shocks result in physician–patient mismatches when hospitals are congested. Specifically, highly specialized physicians who are brought in to treat unscheduled high-risk admissions also treat previously admitted lower-risk patients. This leads to increased treatment intensity for lower-risk patients, which I attribute to persistence in physician practice style. Despite the greater treatment intensity, I find no detectable improvement in health outcomes, which prima facie could be viewed as waste. However, the mismatches observed only at high congestion levels more likely reflect hospitals’ careful assessment of costs and benefits when assigning physicians to patients – maintaining preferred physician–patient matching can be particularly costly when congestion is high. My findings highlight the need to consider both heterogeneity within patient and physician type, and furthermore show how the common phenomenon of demand uncertainty can promote mismatch between these types. The second chapter assesses hospital self-reported facility data quality using annual Institutional Cost Report (ICR). In the United States, hospital facilities are under public and government supervision. The central motivation behind this is that overbuilding and redundancy in health care facilities will lead to overutilization and higher health care costs. However, little is known about the effectiveness of these facility regulation policies. Taking certified capacities recorded by the Department of Health as reliable benchmarks, this paper presents evidence that hospitals upcode their neonatal intensive care unit (NICU) bed levels when reporting capacities in ICR. Reported NICU utilization in ICR is mostly under the top level NICU bed, which matches the bed capacity upcoding pattern. This indicates either significant overutilization which leads to NICU overcrowding, or upcoding in medical billing that results in inflated medical charges. Findings in this paper point to a potentially effective way for regulators and insurers to limit overutilization – improving hospitals’ compliance with their certified capacities. This paper also provides important guidelines for a large body of research that uses ICR data by developing an assessment of ICR data quality. The third chapter, which is joint work with Douglas Almond, measures gender inequality in perinatal health among Chinese-American newborns. The literature on “missing girls" suggests a net preference for sons both in China and among Chinese immigrants to the West. Perhaps surprisingly, we find that newborn Chinese-American girls are treated more intensively in US hospitals: they are kept longer following delivery, have more medical procedures performed, and have more hospital charges than predicted (by the non-Chinese gender difference). What might explain more aggressive medical treatment? We posit that hospitals are responding to worse health at birth of Chinese-American girls. We document higher rates of low birth weight, congenital anomalies, maternal hypertension, and lower APGAR scores among Chinese American girls – outcomes recorded prior to intensive neonatal medical care and relative to the non-Chinese gender gap. To the best of our knowledge, we are the first to find that son preference may also compromise “survivor" health at birth. On net, compromised newborn health seems to outweigh the benefit of more aggressive neonatal hospital care for girls. Relative to non-Chinese gender differences, death on the first day of life and in the post-neonatal period is more common among Chinese-American girls, i.e. later than sex selection is typically believed to occur.

This dissertation consists of three essays on Health Economics. Chapter 1 analyzes the effects of abortion costs for minors on abortions, sexual behavior, and births. We exploit a 2015 change in parental involvement (PI) laws in Spain as a natural experiment in costs, together with rich population-level data on abortions and births. Using the exact date of teenager birth, we first document a decrease in abortions by 17-years-olds using a difference-in-difference comparison with 18-years-olds, consistent with the law that targeted Spanish minors. Using bunching methods from the Public Finance literature, we show evidence of temporal displacement. Some 17-years-old delayed their abortion and waited until they turned 18 and thereby avoided involving their parents. Second, we consider how the law change may have influenced health-related behaviors, finding implicitly that sexual behaviors changed so as to reduce the likelihood of becoming pregnant before turning 18 (and thereby internalized the cost of parental involvement). This is seen in the permanent shift in the number of abortions at age 18 that exists after removing the temporal displacement abortions around the age 18 threshold and an increase in the number of births to mothers who were pregnant at age 17. This paper finds that an important dimension of risky youth behavior responds to incentives contained in parental notification laws. Chapter 2 analyzes the effects of abortion costs on sex-selection by exploiting a 2010 abortion liberalization in Spain and the difference in son-preferences by nationality and child order documented in the literature. We show using a difference-in-difference comparison a significant increase in the fraction of boys for Chinese parents giving birth to their third child or above relative to children born of Spanish parents. Consistent with the literature, we do not find any effect on the fraction of boys for the first or the second child. Using the provincial number of abortion centers per person as a measure of access to abortion, we show, at the correlation level, that the effects come from those provinces with higher access to abortions. Finally, we find suggestive evidence that birth outcomes of Chinese girls who are the third children, and thus are now more likely to be ``wanted'' after the reform, improve. Gestational weeks increase, and the chance of being born prematurely decrease although our evidence suffers from lack of power. Finally, chapter 3 analyzes the effects of a universal, unconditional cash transfer announcement on birth outcomes by exploiting the 2007 cheque bebé policy in Spain that provided 2,500 euros per child to all mothers giving birth immediately after its announcement (Jul 2007). We use a difference-in-difference analysis comparing those born before and after the announcement. By exploiting the timing of the policy announcement we can avoid the composition effects caused by the incentives to have children generated by the policy. We show that the birth weight of those children born after the policy announcement (Sept-Dec) significantly improved relative to those born before (Apr-Jun) using previous years to control for the seasonal effects. Moreover, we provide suggestive evidence that those who are more vulnerable, as measured by the average municipality income level, parents' marital status, or parents' age, experience the most substantial improvements on birth weight.

The early postnatal period is marked by the rapid acquisition of sensorimotor processing capabilities. Initially responding to a limited set of environmental stimuli with a restricted repertoire of behaviors, mammals exhibit a remarkable proliferation of sensorimotor abilities in the early postnatal period. Central to action selection, reinforcement, and contingency learning are a subcortical set of evolutionarily conserved nuclei called the basal ganglia. The striatum, which is the primary input nucleus of the basal ganglia, receives afferent innervation from throughout the CNS. Its projection neurons (SPNs) integrate these diverse inputs, regulating movement and encoding salient cue-outcome contingencies. Here, using electrophysiological, electrochemical, imaging, and behavioral approaches in mice, I will explore the postnatal maturation of the striatal cholinergic interneuron (ChI), a critical modulator of dopamine signaling, afferent excitation, and SPN excitability. In Chapter 1, I will set the stage for this exploration by reviewing the current literature on striatal postnatal development, including cellular physiology, axonal elaboration and synapse formation, and plasticity expression. I will survey striatal deficits observed in clinical neurodevelopmental conditions such as autism, ADHD, tic disorders, and substance use disorders. I will additionally summarize evidence that the striatum is uniquely vulnerable to physiological and immunological insult, as well as early life adversity. In Chapter 2, I turn my focus specifically to the striatal ChI, uncovering fundamental cell-intrinsic changes that occur postnatally in this population. I will also elaborate on the postnatal maturation of dopamine release properties and regulation thereof by cholinergic signaling from the ChI. In Chapter 3, I investigate the circuit connectivity and circuit-driven firing dynamics of ChIs as they mature postnatally. I utilize a brain slice preparation retaining thalmostriatal afferents in order to assay the ChI pause, a synchronized transient quiescence in ChIs thought to facilitate cue learning and behavioral flexibility. I find that the ChI pause is refined postnatally, dependent on developmental changes in thalamic input strength and the cell- intrinsic expression of specific ionic conductances. Finally, in Chapter 4, I present preliminary evidence that ChI circuit maturation as defined in preceding chapters is delayed by chronic stress exposure postnatally. Following the maternal separation model of early life stress, ChI intrinsic characteristics mature normally, but they retain heightened thalamic innervation and thalamus-driven pause expression.

Thesis (MPH.) -- University of Limpopo, 2021 / Pregnancy and childbearing are most of the crucial milestones in women’s lives as they look forward to becoming mothers. During this time, they have positive expectations while pregnant, however, the physical, hormonal, neurotransmitters and psychosocial changes that occur can make pregnancy to be stressful and overwhelming. The disability associated with depression and its impact on maternal and child health has important implications for public health policy. While the prevalence of postnatal depression is high, there are no prevalence data and associated risk factors on antenatal depression in Helen Franz Hospital of Limpopo Province, South Africa. The purpose of this study was to determine the prevalence and factors associated with depression amongst pregnant women at Helene Franz Hospital. Methodology: A quantitative retrospective design was used in the study and a sample size of 336 was required which was calculated based on the 95% confidence interval, 5% sampling error and 38.5% prevalence of depression amongst pregnant women in KZN. A self-administered questionnaire with close-ended questions which was adopted from the Edinburgh postnatal depression scale was given to the participants to complete. The scoring of the questionnaire was that the maximum score was 30 and the persons who scored 10 or greater were considered depressed according to the Edinburg scale for assessing depression. Data were analysed using SPSS V.21.0 and a p-value of less than 0.05 was considered statistically significant. Results: The participants ranged from 18 to 47 years with the mean age of 27.8±6.9 years. The majority of the pregnant women were in the age groups 20-24 years and 25-29 years. The mean depression score for pregnant women was 7.87±5.2 and ranged from 0 to 23. The prevalence rate of depression symptoms was 31%. Maternal age was not significantly associated with depression and a significantly higher proportion of married pregnant women were depressed as compared to unmarried women at p=0.017. Pregnant women who smoke were significantly more likely to be depressed than those who do not smoke at p=0.002. Pregnant women without financial support from partnerwere significantly likely to be depressed than those who receive financial support at p-=0.002. A significantly greater proportion of pregnant women with partner violent were likely to be depressed than those with non-violent partner at p <0.001. Pregnant women in relationships with unemployed spouses were significantly likely to experience depression than the employed spouse at p=0.035. lastly, pregnant women in relationship with a spouse with lower educational level were significantly likely to be depressed than the other groups at p-.006. Conclusion: The prevalence of depression among pregnant women was high and the main risk factors involved in the onset of antenatal depression have highlighted a complex multifactorial aetiology. These are related to different sources of chronic diseases, psychosocial, environmental, obstetric and pregnancy- related risk factors have been highlighted. Correctly identifying women at risk of suffering from depression would provide an opportunity to target those women who would benefit from preventive and supportive interventions. Therefore, a psychosocial assessment, in the sense of a comprehensive and multidimensional evaluation of a woman's psychosocial circumstances should be common practice for all women during the antenatal period. Key concepts Antenatal care; Pregnancy; Childbearing; Depression; Psychosocial

The mechanical function of the uterine cervix is critical for a healthy pregnancy. During pregnancy, the cervix undergoes a significant remodeling from a mechanical barrier into a compliant structure to allow for a successful delivery. A too early or too late cervical softening will lead to spontaneous preterm births (sPTB) or dystocia. PTB is a leading cause of neonatal death, affecting 15 million newly born babies each year around the world. According to CDC, the rate of PTB increases in recent years. Dystocia increases the risk to both mother and newborn babies, leading to neonatal asphyxia, neonatal infection, uterine rupture, or other dangerous sequelae. Therefore, it is significant to have a better correlation of the mechanical properties change and the biological remodeling process of the cervix during pregnancy. This thesis will focus on (1) mechanical experiments of the human cervix, and (2) the development of a material constitutive model for cervix to characterize the complex microstructure-related mechanical property of the cervix. In this thesis, a spherical indentation test was designed and conducted on human cervical samples sliced perpendicular to the axial direction, to characterize the compressive mechanical behavior of the human cervix. A uniaxial tensile was designed and conducted on the strip samples cut along and perpendicular to the preferential fiber direction from the indentation samples, to characterize the tensile mechanical behavior of the cervix. Based on the detailed experimental investigation, a nonlinear time-dependent anisotropic microstructure-inspired constitutive model has been developed. The basic idea of the model is that the mechanical behavior of the human cervix can be decomposed into an equilibrium and a time-dependent part, and the tension and compression mechanical behaviors are caused by disparate mechanisms. Specifically, the collagen fibrous network plays a major role in the tensile mechanical response, while proteoglycans (PGs), glycosaminoglycans (PGs),, and liquid cause the compressive mechanical response. The tensile time-dependent mechanical behavior of the human cervix is mostly attributed to the interactions between the collagen fiber and other components, while the compressive time-dependent mechanical behavior is mainly attributed to the porous effect. The equilibrium and time-dependent mechanical responses have been well captured using the model, and the results reveal the connection between the ECM microstructure remodeling and mechanical properties change during pregnancy.

Hypoplastic left heat syndrome (HLHS) is a complex cardiac malformation in neonates suffering from congenital heart disease and occurs in nearly 1 per 5000 births. HLHS is uniformly fatal within the first hours or days after birth as the severly malformed anatomies of the left ventricle, mitral, and aortic valves, and ascending aorta are not compatable with life. The regularly implemented treatment, the Norwood operation, is a complex open heart procedure that attempts to establish univenticular circulation by removing the atrial septum ( communicating the right and left ventricle), reconstructing the malformed aortic arch, and connecting the main pulmonary artery into the reconstructed arch to allow direct perfusion from the right ventricle into the systemic circulation. A relatively new treatment being utilized,the Hybrid Norwood procedure, involves a less invasive strategy to establish univentricular circulation that avoids a cardiopulmonary bypass (heart-lung machine), deliberate cardiac arrest, and circulatroy arrest of the patient during the procedure. The resulting systemic-pulmonary circulation is unconventional; blood is pumped simotaneously and in parallel to the systemic and pulmonary arteries after the procedure. Cardiac surgeons are deeply interested in understanding the global and local hemodynamics of this anotomical configuration. To this end, a multiscale model of the entire circulatory system was developed utilizing an electrical lumped parameter model for the peripheralor distal circulation coupled with a #D Computational Fluid Dynamics (CFD) model to understand the local hemodynamics. The lumped parameter (LP) model is mainly a closed loop circut comprised of RLC comartments that model cardiac function as well as the viscous drag, flow intertia, and compliance of the different atrial and venous beds in the body. A system of 32 first-order differential equations is formulated and solved for the LP model using a fourth-order adaptive Runge-Kutta solver. The output pressure and flow waveforms obtained from the LP model are imposed as boundary conditions on the CFD model. Coupling of the two models is done through an iterative process where the parameters in the LP model are adjusted to match the CFD solution. The CFD model domain is a representative HLHS anatomy of an infant after undergoing the Hybrid Norwood procedure and is comprised of the neo-aorta, pulmonary roots, aortic arch with branching arteries, and pulmonary arteries. The flow field is solved over several cardiac cycles using an implicit-unsteady RANS equation solver with the k-epsilon turbulence model.; Hypoplastic left heart syndrome (HLHS) is a complex cardiac malformation in neonates suffering from congenital heart disease and occurs in nearly 1 per 5000 births. HLHS is uniformly fatal within the first hours or days after birth as the severely malformed anatomies of the left ventricle, mitral and aortic valves, and ascending aorta are not compatible with life. The regularly implemented treatment, the Norwood operation, is a complex open heart procedure that attempts to establish univentricular circulation by removing the atrial septum (communicating the right and left ventricle), reconstructing the malformed aortic arch, and connecting the main pulmonary artery into the reconstructed arch to allow direct perfusion from the right ventricle into the systemic circulation. A relatively new treatment being utilized, the Hybrid Norwood procedure, involves a less invasive strategy to establish univentricular circulation that avoids a cardiopulmonary bypass (heart-lung machine), deliberate cardiac arrest, and circulatory arrest of the patient during the procedure. The resulting systemic-pulmonary circulation is unconventional; blood is pumped simultaneously and in parallel to the systemic and pulmonary arteries after the procedure. Cardiac surgeons are deeply interested in understanding the global and local hemodynamics of this anatomical configuration. To this end, a multiscale model of the entire circulatory system was developed utilizing an electrical lumped parameter model for the peripheral or distal circulation coupled with a 3D Computational Fluid Dynamics (CFD) model to understand the local hemodynamics. The lumped parameter (LP) model is mainly a closed loop circuit comprised of RLC compartments that model cardiac function as well as the viscous drag, flow inertia, and compliance of the different arterial and venous beds in the body.

No description available.

While a variety of researchers have identified periodic recurrences in infant behavioral state with various time-series techniques, the appropriateness of techniques which identify periodic recurrences in all infants at all ages have been questioned. The purpose of this study was to compare the utility of four time-series techniques used in the analysis of periodic recurrences in the behavioral state of 21 newborns during a 2 hour observation period. For quiet sleep, active sleep and awake states the period length of the major rhythm was estimated by 1) binary spectrum analysis, 2) binary autocorrelation, 3) renewal time analysis, and 4) kappa analysis. Repeated measures analysis of variance showed that the period lengths identified by renewal time analysis were significantly shorter than those identified by the other three techniques for quiet and active sleep. Further, the kappa analysis and binary autocorrelation showed that awake states were significantly shorter than both active sleep and quiet sleep. Pearson product-moment correlations showed that the relation between the periods for a given state identified by each analysis ranged from .01 to .83. The results indicate that 1) renewal time analysis is more sensitive to state interruptions than the other techniques, 2) awake states may have a different period length than either quiet sleep or active sleep, and 3) although the four techniques identified state recurrences in almost all of the neonates, only a smaller subgroup of neonates displayed a pattern of technique agreement that would indicate a clearly rhythmic pattern of states. / M.S.

A clinical need exists for a blood oxygenator and pumping system for the support of neonates with respiratory deficiencies. Such systems now available for support of adults are not suitable for neonatal patients. In vitro evaluation of a new blood oxygenator and blood pumping system was performed. The data obtained suggested that this system may be applicable to neonates. In vivo studies with rabbits to further analyze the new system were done. Preliminary data from these studies indicate that the new blood oxygenator and blood pump system may be applicable to supporting neonates with respiratory deficiencies. Suggestions for future development of this system are presented. / Master of Science

Previous studies have reported that spontaneous startles occur most frequently in the quiet sleep states, and have posited an energy release model in which spontaneous startles occur to release energy which would otherwise wake the infant. An alternative suggestion is that startles serve a homeostatic function by increasing the activity of the infant during periods of low arousal. The purpose of the current study was to examine the function of spontaneous startles using the ongoing cardiac and respiratory activity as indices of arousal. Twenty-six newborn infants were assigned to two groups. The first group was exposed to auditory stimulation which previously had been shown to decrease heart rate and respiratory rate for the first half of the one hour observation period. To the extent that spontaneous startles are related to periods of low arousal, decreasing the ongoing activity via the auditory intervention was expected to increase the rate of startles. The second group received no auditory stimulation. The occurrence of spontaneous startles was preceded by periods of lower than average heart rate and decreasing respiratory rate. Startles were followed by periods of increasing heart rate and further decreasing respiratory rate. In addition, the auditory intervention group reliably showed both a lower heart rate and an increased number of startles while exposed to the auditory stimulation, while the nonintervention group showed comparable rates of startles and heart rates in both halves of the observation period. Further, regardless of group status, most infants had their higher rate of startles in the period in which they had their lower heart rate. Finding lower heart rate and decreasing respiratory rate preceding startles, and lower heart rate and increased number of startles when exposed to the auditory stimulation, suggests that spontaneous startles modulate periods of low arousal in newborn infants. / Ph. D.