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.

Bakgrund: Av de ca 110 000 – 120 000 barn som föds årligen i Sverige, behöver drygt tio procent vård på neonatalavdelning. Att amma sitt barn har väldokumenterade fördelar och är särskilt anpassat för det individuella barnets behov vilket ger fördelar både på fullgångna och prematurfödda barn. Syfte: Syftet med studien är att belysa faktorer vilka påverkar det amningsfrämjande arbetet på neonatalavdelningar. Metod: Allmän litteraturöversikt som innefattar totalt 16 vetenskapliga artiklar. Samtliga artiklar vilka inkluderats i resultatet har granskats enligt kvalitetsmall. Resultat: Amning och bröstmjölk väcker starka och blandade känslor hos vårdpersonalen. Vårdpersonal som genomgått någon form av utbildning inom området amning var generellt mer positivt inställda till att ge amningsstöd trots påverkan på arbetsbördan. Flaskmatning sågs som ett bekvämt alternativ även om bröstmjölkens fördelar var väl kända. Slutsats: I vilken utsträckning amningsstöd utförs och vilken kvalitet det har beror på stor del på vårdpersonalens egna upplevelser och känslor gällande amning. Då få studier fanns att tillgå är det en indikation på att vidare forskning inom området behövs. / Background: In Sweden, approximately 110,000 – 120,000 babies are born every year. More than ten percent of all newborn babies born in Sweden are in need of care in neonatal care units. Breastfeeding has well-documented benefits and is specifically tailored to the needs of the individual child, providing benefits for both full-term and premature born babies. Aim: The purpose of the study is to shed light on factors that affect breastfeeding work in neonatal wards. Method: General literature review. Including a total of 16 scientific articles. All articles included in the results have been reviewed according to the quality template.  Results: Breastfeeding and breast milk triggered strong and mixed feelings in the health care workers. Healthcare professionals who had undergone some form of training in the field of breastfeeding were generally more positive towards providing breastfeeding support despite the impact on the workload. Bottle feeding was seen as a convenient option although the benefits of breast milk were well known. Conclusion: The extent to which breastfeeding support is performed and the quality of it depends largely on the healthcare staff's own experiences and feelings regarding breastfeeding. Since few studies were available, it is an indication that further research in the field is needed.

Family-centered care (FCC) is considered the gold standard for care delivery in the Neonatal Intensive Care Unit (NICU). However, there are challenges with the implementation of FCC in practice and there is limited literature about how to tailor this approach for specialized NICU populations. To explore FCC for surgical neonates in the NICU, the concept was explored using Roger’s evolutionary concept analysis. Results illustrate that FCC in the NICU is a philosophy or care, rather than a set of interventions. The subsequent cross-sectional descriptive exploratory study showed that the surgical infants in our sample (n=11) received a limited amount of skin-to-skin care (median 0 mins/day) and parents reported challenges to being involved in their infant’s care. This thesis supports the challenges with the implementation of FCC in practice and both the need to consider multiple perspectives and the need for broader systemic change in order to support a FCC philosophy.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Background: The role of the physiotherapist in the neonatal intensive care unit is unclear. How other neonatal healthcare professionals and physiotherapists themselves perceive their role in the management of neonates, their practice patterns and services, their role in the neonatal intensive care multidisciplinary team, their use of evidence-based practice and awareness of the profession in this setting has not been well explored. This information is lacking in the South African healthcare context as well. Therefore, the aim of the study was to explore and describe the perception of doctors, nurses and physiotherapists of the role of the physiotherapist in public and private sector neonatal intensive care units in South Africa. Methods: A qualitative exploratory research design was used. All medical practitioners (paediatricians and neonatologists), nurses and physiotherapists working in the neonatal intensive care units in two private sector and two public sector hospitals in the Cape Metropole region in the Western Cape South Africa who provided consent to participate were included. An inclusive (total population) sampling method was used where all healthcare professionals working in these units were invited to an individual face-to-face audiotaped interview using a semi-structured interview guide and conducted by the researcher at a time and place convenient to the participants following informed consent. Data was transcribed verbatim and analysed using both deductive and inductive thematic content analysis to develop codes, categories and themes. Trustworthiness was ensured by ensuring credibility, conformability, dependability and transferability of data. Ethics was obtained from the relevant Institutional Review Board. Results: Twenty-one healthcare professionals participated, including doctors (n=5), nurses (n=6) and physiotherapists (n=10). The mean age in years of the participants was 41+/–11 years with the physiotherapists having the lowest mean age. The participants had various years of general and neonatal intensive care experience and physiotherapists in specific only had basic undergraduate qualifications with minimal specialised training in neonatal intensive care. Five major themes emerged namely: i) the role of the physiotherapists in the management of the neonatal ICU patient, ii) practice patterns and services iii) teamwork iv) training and qualifications including evidence-based practice, v) awareness of and exposure to neonatal intensive care physiotherapy. Conclusion: Physiotherapists working in this neonatal intensive care setting need to promote their profession through education of other neonatal healthcare professionals in order to improve awareness, referral patterns and integration into the multidisciplinary team. Evidence-based practices and improving training and skills development in the area of neonatal physiotherapy can be further explored in this setting.

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Background: NICU experiences pose significant challenges for parents, especially immigrants, necessitating comprehensive support. South Asian immigrants, comprising 25% of Canada's visible minority population, face unique adversities related to gender roles, hindering access to essential health services and integration. Coupled with unfavourable social determinants of health (SDoH), these challenges worsen issues like inadequate prenatal care, education, and nutrition, predictors of adverse maternal and neonatal health outcomes. Existing studies lack insight into the specific experiences of South Asian immigrant mothers in the NICU. This study investigates these experiences. Methods: Using a qualitative descriptive approach, we recruited four participants for semi-structured interviews, supplemented by a demographic questionnaire and participant observation. Qualitative content analysis was employed for data analysis. Findings: Four key themes were identified from the interviews: (1) Seeking Understanding, (2) Cultural Influence on NICU Experience, (3) Motherhood Journey, and (4) Circle of Care. Implications: This study fills a gap in NICU research for South Asian immigrant women, providing a foundation for future nursing research and practice. It underscores the importance of communication and preparation for discharge delays to ease parental concerns. Additionally, it emphasizes culturally sensitive care practices and encourages further exploration of cultural influences on hospital experiences. Insights from this study can benefit other ethno-racial immigrant groups. / Thesis / Master of Science in Nursing (MSN) / Existing research offers insights into the general challenges and distress often associated with mothers' experiences in the NICU. However, there is little evidence to understand the specific experiences of South Asian immigrant mothers within this context. The objective of this thesis is to describe and understand the experiences in the NICU reported by this population. Employing a qualitative description methodology, this study engaged four eligible participants. Data collection entailed semi-structured interviews alongside a demographic questionnaire. Employing qualitative content analysis, four overarching themes were identified: (1) Seeking to Understand, (2) The Impact of South Asian Culture on the NICU Experience, (3) Becoming a Mother One Step at a Time, and (4) Circle of Care.

Yes / Aim and Objectives: To explore fathers' views and experiences of providing Kangaroo Care (KC) to their baby cared for in a Neonatal Intensive Care Unit (NICU). Kangaroo Care has been known to improve the health outcome for preterm, low birth weight and medically vulnerable term infants and achieve the optimal perinatal health wellbeing for parents and infants. Historically, mothers are considered as the dominant KC providers, whereas fathers are spectators and have been overlooked. Little is known about the fathers' perspectives in providing KC in NICUs. Methods: Individual semi-structured interviews were conducted with 10 fathers who delivered KC to their baby when in the NICU. Data were analysed using Braun and Clarke's six-phase thematical framework. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed to report this qualitative study. Findings: Fathers in this study identified they were passing a silent language of love and connecting with their baby by the act of KC in a challenging environment. Three themes emerged: ‘Positive psychological connection’, ‘Embracing father-infant Kangaroo Care’ and ‘Challenges to father-infant Kangaroo Care’. Conclusion: The findings of this study show KC enhances the bonding and attachment between fathers and infants. The conceptualisation of the paternal role in caregiving to a newborn is evolving as a contemporary practice. Further research is warranted to confirm or refute the study findings. Policies and facilities should be modified to include father–infant KC within the fields of neonatal care. Relevance to Clinical Practice: It is important for nurses and other health professionals to support and enable fathers to give KC. Father–infant KC is recommended in neonatal care settings. / Open access publishing facilitated by University of South Australia, as part of the Wiley - University of South Australia agreement via the Council of Australian University Librarians.

Yes / . Kangaroo care (KC) has been used widely in neonatal care to promote bonding/attachment and neurodevelopment for preterm and term infants. However, current literature suggests that research mainly focuses on infants' and mothers' experiences. The role of fathers in caring for their infant/child is changing and evolving in many countries around the globe. Yet little is known about fathers' experiences of KC in neonatal units. This review, therefore, aims to scope the current evidence of Father-infant KC (Father KC) in Neonatal Intensive Care Units (NICUs). Research question. What impact does KC have upon fathers when their baby is cared for in NIUCs? Search method. A scoping review was conducted and guided by the framework of Arksey and O'Malley (2005). The data sources consisted of Medline, Embase, America Psychological Association (APA) PsycInfo, Emcare, Cochrane Central, Web of Science, Google Scholar and ProQuest. The study inclusion criteria were: (1) studies involving fathers who had experience of KC with their baby whilst in Neonatal Intensive Care Units (NICUs), and other neonatal care settings, such as Special Care Baby Nursery (SCBU), delivery/labour room and postnatal ward; (2) literature published from 2000 to 2020; (3) primary studies including qualitative, quantitative, and mixed methods studies; (4) studies published in English. Results. The total number of studies identified were 13. Seven studies were qualitative and six were quantitative. None were mixed methods. Studies reported several positive KC benefits on fathers, such as reduced stress, promotion of paternal role and enhanced father-infant bond. It was highlighted that KC could be time-consuming for fathers and challenging to practise when balancing work and family life commitments. Conclusion. This review provides evidence that KC practice has health and wellbeing benefits for fathers and infants in NICUs and other relevant neonatal care settings, The findings of this review support the justification to promote Father KC in NICU environments, and guide policies to include father involvement. Implementing Father KC in NICU settings will assist fathers to care and connect with their baby. Further research is needed to explore how to facilitate and evaluate KC education for fathers from diverse s and cultures.